Section A: Delivery - hst.org.za Health Barometers/4... · LP MP NC NW WC 75. Section A: Delivery....

Delivery in facility under 18 years rate by NHI district, 2013/14

Percentage

OR Tambo: DC15

uMzinyathi: DC24

G Sibande: DC30

Amajuba: DC25

Pixley ka Seme: DC7

uMgungundlovu: DC22

Vhembe: DC34

Eden: DC4

T Mofutsanyana: DC19

Dr K Kaunda: DC40

Tshwane: TSH

5 10

12.2

7.8

5.4

9.1

10.0

9.8

8.4

9.9

9.4

6.1

7.9SA average: 7.8

Target: 6.9ProvincesECFSGPKZNLPMPNCNWWC

Delivery in facility under 18 years rate by province, 2013/14

Percentage [Source: DHIS]

NC

EC

KZN

MP

LP

FS

NW

WC

GP

5 10

10.1

7.1

5.7

9.3

7.9

9.1

10.2

7.0

6.3SA average: 7.8

Target: 6.9 ProvincesECFSGPKZNLPMPNCNWWC

75

Section A: Delivery

4 Delivery Nienke van Schaik

This chapter covers several aspects of maternal health related to delivery as well as indicators of obstetric and intra-partum care. The following indicators are presented: delivery rate in facility under 18 years, delivery by Caesarean section rate, stillbirth rate in facility, inpatient early neonatal death rate, and maternal mortality in facility ratio.

The indicators represent what is happening at public health facilities in South Africa, as only a small number of private facilities provide data to be incorporated into the District Health Information Software (DHIS).

In 2013/14, the DHIS recorded 943 848 deliveries (3 547 less than in 2012/13), 230 479 Caesarean sections, 937 082 live births and 20 558 stillbirths.

4.1 Delivery rate in facility under 18 years

The delivery rate in facility under 18 years indicator measures the percentage of all deliveries that occur in women younger than 18 years. The numerator is the number of deliveries in women under 18 years of age, while the denominator represents all deliveries that have been recorded at health facilities in South Africa.

This outcome indicator is used as a proxy to track success in the prevention of teenage pregnancies. It also assists in tracking the improvements in maternal health as outlined in Millennium Development Goal 5b.

The delivery rate in facility under 18 years in South Africa was on the decline but showed a marginal increase from 7.7% in 2012/13 to 7.8% in 2013/14. Overall there were 74 070 women under the age of 18 who gave birth in South Africa in 2013/14. This was 1 166 more than in 2012/13.

Provincially, the highest delivery rate in facility under 18 years for the past year was in the Northern Cape (NC) (10.2%), followed by the Eastern Cape (EC) (10.1%) (see Figure 1). The lowest was in Gauteng (GP) (5.7%) even though there was an increase of 0.9 percentage points from 4.8% in the previous year. The rate declined in EC, Free State (FS), North West (NW) and Western Cape (WC). It was stable in KwaZulu-Natal (KZN) and Northern Cape (NC), and increased marginally in Limpopo (LP) and Mpumalanga (MP).

Figure 1: Delivery in facility under 18 years rate by province, 2013/14

DC6

DC7

DC8

DC10

DC5

DC36

DC39

DC1

DC16

DC13

DC19DC18

DC30

DC4

DC2

DC38

DC32

DC45

DC14

DC34

DC12

DC35

DC20

DC33

DC37

DC31

DC3

DC9

DC26

DC40

DC27

DC47

DC15

DC23

DC44

DC43

DC22

DC24

DC28

TSH

MAN

DC25

TSH

DC42

DC48 EKUJHB

Gauteng

LegendProvince

District

DELFCU18_20134.9 - 6.1

6.2 - 7.4

7.5 - 8.9

9.0 - 10.7

10.8 - 12.9

76

Section A: Delivery

The delivery rate in facility under 18 years at district level (see Figure 2) ranged from 4.9% in Ekurhuleni (GP) to 12.9% in Alfred Nzo (EC) which also had the highest rate in 2012/13. This district also has the second lowest couple year protection rate at 20.6%. Four of the five districts with the highest delivery rate in facility under 18 years are in the EC. The percentage of the population aged 10 to 17 years is higher than average in these districts, which may partially explain the higher percentage of delivery rates in young women.

Eight of the 11 NHI pilot districts had delivery rates in facility under 18 years higher than the national average. The rates varied from 5.4% in Tshwane (GP) to 12.2% in OR Tambo (EC).

Map 1: Delivery in facility under 18 years rate by district, 2013/14

Delivery in facility under 18 years rate by district, 2013/14


A Nzo: DC44Joe Gqabi: DC14

JT Gaetsewe: DC45OR Tambo: DC15Amathole: DC12

ZF Mgcawu: DC8uMkhanyakude: DC27

iLembe: DC29C Hani: DC13

Ugu: DC21Zululand: DC26

uMzinyathi: DC24Harry Gwala: DC43RS Mompati: DC39

Ehlanzeni: DC32G Sibande: DC30

Amajuba: DC25Pixley ka Seme: DC7

uThukela: DC23uMgungundlovu: DC22

Namakwa: DC6Frances Baard: DC9

West Coast: DC1Vhembe: DC34Overberg: DC3Mopani: DC33

eThekwini: ETHuThungulu: DC28

Eden: DC4Cacadu: DC10

T Mofutsanyana: DC19Cape Winelands: DC2

Sekhukhune: DC47Waterberg: DC36

Central Karoo: DC5Capricorn: DC35

NM Molema: DC38Fezile Dabi: DC20

Lejweleputswa: DC18Sedibeng: DC42Mangaung: MANNkangala: DC31

N Mandela Bay: NMAJohannesburg: JHB

Buffalo City: BUFBojanala: DC37

Dr K Kaunda: DC40Xhariep: DC16

West Rand: DC48Cape Town: CPT

Tshwane: TSHEkurhuleni: EKU

5 10

NHI

NHI

NHI

NHI

NHI

NHI

NHI

NHI

NHI

NHI

NHI

6.1

7.9

11.7

10.7

12.4

12.2

12.9

6.7

5.6

6.9

7.8

7.1

6.8 6.9

5.5

4.9

6.5

5.4

10.6

9.1 9.3

10.0

9.8

10.2

11.3

8.0

10.7

10.0

8.0 8.1

8.4

7.4

7.6 7.7

9.9

6.8

9.9

12.2

8.9

9.4

11.5

8.8

6.1

7.2

10.0

6.1

5.5

8.4

7.7

8.2

7.9

7.6

SA average: 7.8

Target: 6.9

ProvincesECFSGPKZNLPMPNCNWWC

77

Section A: Delivery

Figure 2: Delivery in facility under 18 years rate by district, 2013/14

78

Section A: Delivery

An overview of annual trends for the districts, grouped by province (see Figure 3), shows that there were downward trends in some provinces but that there was still a fair amount of fluctuation. Johannesburg (GP) was the district with the lowest rate in the previous year at 4.0% but this increased by 2.5 percentage points to 6.5% in 2013/14. Joe Gqabi (EC) and iLembe (KZN) also showed increases of 1.5 and 1.4 percentage points respectively. The largest declines were noted in Xhariep (FS) where the rate declined by 3.8 percentage points (probably linked to small numbers), Cape Winelands (WC) by 1.8 percentage points and Central Karoo (WC) by 1.4 percentage points.

The uptake of the sub-dermal contraceptive implant by teenagers may play a role in changing trends. The impact of the Integrated School Health Programme (ISHP), which promotes contraception use among youth and also seeks to address teenage pregnancy through supporting peer education and health promotion in schools, should be assessed.a

At DHB workshops conducted in 2013 and 2014, reasons mentioned for a high delivery rate in facility under 18 years included:

✦ a failure or lack of education through school health programmes;

✦ cultural issues including that one should have a child before marriage; and

✦ poverty.

The importance of access to family planning and education cannot be over-emphasised in order to further reduce the number of deliveries in women under the age of 18.

a South African National Department of Health. Status of Family Planning in South Africa: RMCH Fact Sheet 2013. http://www.rmchsa.org/wp-content/uploads/2013/08/Fact-sheet-Status-of-Family-Planning-in-South-Africa.pdf.

Annual trends: Delivery in facility under 18 years rate

Perc

enta

ge

0

5

10

15

EC FS

●●

●●

●

●

●

● ● ●●

●

GP

0

5

10

15

KZN

●

●●

● ● ●● ● ● ● ●

●

LP MP

0

5

10

15

2002

/03

2003

/04

2004

/05

2005

/06

2006

/07

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

2013

/14

NC

2002

/03

2003

/04

2004

/05

2005

/06

2006

/07

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

2013

/14

NW20

02/0

320

03/0

420

04/0

520

05/0

620

06/0

720

07/0

820

08/0

920

09/1

020

10/1

120

11/1

220

12/1

320

13/1

4

●

●

● ●

●●

●●

●

● ● ●

WC

EC A NzoEC AmatholeEC Buffalo CityEC C HaniEC CacaduEC Joe GqabiEC N Mandela BayEC OR TamboFS Fezile DabiFS LejweleputswaFS MangaungFS T MofutsanyanaFS Xhariep

GP EkurhuleniGP JohannesburgGP SedibengGP TshwaneGP West RandKZN AmajubaKZN eThekwiniKZN Harry GwalaKZN iLembeKZN UguKZN uMgungundlovuKZN uMkhanyakudeKZN uMzinyathi

KZN uThukelaKZN uThunguluKZN ZululandLP CapricornLP MopaniLP SekhukhuneLP VhembeLP WaterbergMP EhlanzeniMP G SibandeMP NkangalaNC Frances BaardNC JT Gaetsewe

NC NamakwaNC Pixley ka SemeNC ZF MgcawuNW BojanalaNW Dr K KaundaNW NM MolemaNW RS MompatiWC Cape TownWC Cape WinelandsWC Central KarooWC EdenWC OverbergWC West Coast

●

●

●

79

Section A: Delivery

Figure 3: Annual trends: Delivery in facility under 18 years rate

Annual trends: Delivery in facility under 18 years rate by SEQ

Perc

enta

ge

0

5

10

15

2002

/03

2003

/04

2004

/05

2005

/06

2006

/07

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

2013

/14

SEQ 1

2002

/03

2003

/04

2004

/05

2005

/06

2006

/07

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

2013

/14

●

●

●

●

●● ● ● ●

●●

●

SEQ 2

2002

/03

2003

/04

2004

/05

2005

/06

2006

/07

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

2013

/14

SEQ 3

2002

/03

2003

/04

2004

/05

2005

/06

2006

/07

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

2013

/14

●

●

●

●

●

●

●

●

●

●

● ●

SEQ 4

2002

/03

2003

/04

2004

/05

2005

/06

2006

/07

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

2013

/14

●

●

●

●

●

●

●

● ● ●

●

●

SEQ 5

1 A Nzo1 Amathole1 C Hani1 Harry Gwala1 Joe Gqabi1 OR Tambo1 RS Mompati1 Sekhukhune1 uMkhanyakude1 uMzinyathi1 Zululand2 Capricorn2 iLembe

2 JT Gaetsewe2 Mopani2 NM Molema2 Pixley ka Seme2 Ugu2 uThukela2 uThungulu2 Vhembe3 Amajuba3 Bojanala3 Cacadu3 Ehlanzeni3 G Sibande

3 T Mofutsanyana3 uMgungundlovu3 Waterberg3 Xhariep3 ZF Mgcawu4 Buffalo City4 Central Karoo4 Dr K Kaunda4 Eden4 Fezile Dabi4 Frances Baard4 Lejweleputswa4 Namakwa

4 Nkangala4 West Rand5 Cape Town5 Cape Winelands5 Ekurhuleni5 eThekwini5 Johannesburg5 Mangaung5 N Mandela Bay5 Overberg5 Sedibeng5 Tshwane5 West Coast

●

●

●

80

Section A: Delivery

Figure 4: Delivery in facility under 18 years rate by SEQ

81

Section A: Delivery

4.2 Delivery by Caesarean section rate

The delivery by Caesarean section (C-section) rate remains an important indicator of access to essential obstetric care and is one of the key maternal health indicators.

This indicator measures the percentage of deliveries in district hospitals that are done by C-section. The numerator is the number of C-sections conducted in the facility and the denominator is the number of deliveries that took place in that facility over the same time period. It is thus a facility-based and not a population-based indicator.

In the 2013 National Indicator Data Set (NIDS), which came into effect in April 2013, no specific target has been set for the C-section rate. In June 2010, the World Health Organization officially withdrew its previous recommendation of a 15 per cent C-section rate, stating that “There is no empirical evidence for an optimum percentage. What matters most is that all women who need Caesarean Sections receive them”.b

However, the perception in South Africa is that the C-section rate is too high and that this is a matter of concern.c Identifying the common indications for C-sections can lead to better understanding of the high rates of C-section and associations with morbidity and mortality which can lead to improvements in antenatal services and emergency obstetric care. A method for this has been suggested by the National Department of Health (NDoH) in their publication “Saving Mothers: Caesarean Section Monograph 2013”.d Bleeding during and after C-sections remains one the leading causes of maternal deaths due to obstetric haemorrhage. In 2012, 19 of the 230 maternal deaths (8.3%) due to obstetric haemorrhage were as a result of bleeding during C-section, and 62 of the 230 (27.0%) were due to bleeding after C-section.e

Variations in C-section rates lie in variations in thresholds for intervention both at an institutional and practitioner level, as well as variations in the models of care offered.f The variation in the C-section rate by level of care nationally is shown in Table 1 and in Figure 5.

The overall C-section rate for South Africa, based on all public sector facilities and a small number of private hospitals, was 24.4%, a 1.2 percentage point increase from 2012/13. In total there were 943 848 deliveries and 230 479 C-sections.

There were more data from private hospitals in 2013/14 than in 2012/13 with 73.9% of the 8 945 reported deliveries being C-sections. The C-section rate for public sector hospitals alone was 23.9%.

The majority of deliveries (80.5%) took place at hospitals (as compared to main primary health care or other facilities), as did all but 50 C-sections. At primary health care level, including district hospitals, community health centres, midwife obstetric units and clinics, 59.7% of deliveries took place.

Overall the highest absolute number of C-sections was at regional hospitals (84 919), followed by district hospitals (82 840), tertiary hospitals (30 180) and central hospitals (23 662), with the C-section rates being 36.4%, 21.8%, 39.6% and 42.8% respectively.

Table 1: Caesarean section rate by facility type hospitals, main PHC facilities and other facilities

Caesarean Section rateClassification Type C-Section

RateNumber of C-Sections

Total number of deliveries

Proportion of total deliveries %

Hospitals District Hospital 21.8 82 840 379 807 40.2

Regional Hospital 36.4 84 919 233 161 24.7

Tertiary Hospital 39.6 30 180 76 150 8.1

Central Hospital 42.8 23 662 55 337 5.9

Specialised Psychiatric Hospital - - 116 0.0

Specialised TB Hospital 37.3 2 220 5 952 0.6

Private Hospital 73.9 6 608 8 945 0.9

Total 30.3 230 429 759 468 80.5

b Roxby P. Should there be a limit on Caesareans? BBC News, 30 June 2010. http://www.bbc.co.uk/news/10448034

c Health reporter. Caesarean rates in public healthcare facilities concerning: Motsoaledi. TimesLive, 29 October 2013. http://www.timeslive.co.za/politics/2013/10/29/caesarean-rates-in-public-healthcare-facilities-concerning-motsoaledi

d www.doh.gov.za/docs/policy/2013/CAESAREAN_BOOKLET.pdf

e Pattinson R, Fawcus S, Moodley J. Tenth interim report on Confidential Enquiries into Maternal Deaths in South Africa 2011 and 2012. Pretoria: National Department of Health, 2013.

f Knight M, Sullivan EA. Variation in caesarean delivery rates. BMJ. 2010;341:c5255. Epub 2010/10/12.

Prov

0 10 20 30 40 50 60 70 80Indicator Value

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%% of denominator

EC

FS

GP

KZN

LP

MP

NC

NW

WC

SA

32.5

78.5

48.5

40.9

35.8

24.9

29.8

40.8

47.7

22.3

27.7

21.8

63.3

42.8 73.9

54.617.6

25.6

26.0

69.0

14.0

79.0

42.4

19.4

61.4

23.2

56.2

23.2

41.1

72.1

44.10.5

0.0

0.0

0.0

0.1

14.2%40.2%24.7%

14.1%

17.5%

17.1%

11.4%

20.8%

26.0%

10.9%

20.7%

14.2%

30.0%

22.5%

52.0%

50.6%

15.7%

45.2%

57.8%

59.3%

45.1%

25.9%

34.4%

22.1%

30.5%

38.0%

14.5%

13.6%

10.7%

31.0%

29.0%

21.2%

11.4%

10.6%

12.4%

5.2%8.1%5.9%

6.8%

7.2% 7.8%

8.1%

5.7%

7.1%

Caesarean sect rate, by level of care, FY 2014

OrgUnitType (group)Clinic & Special ClinicCommunity Health CentreMidwife Obstetrics UnitOtherDistrict HospitalRegional HospitalProvincial Tertiary HospitalNational Central HospitalSpecialised HospitalsPrivate Hospital

82

Section A: Delivery

Caesarean Section rateClassification Type C-Section

RateNumber of C-Sections

Total number of deliveries

Proportion of total deliveries %

Main PHC facilities Clinic 0.1 35 48 082 5.1

Community Day Centre - - 5 865 0.6

Community Health Centre - 10 128 087 13.6

Total 0.0 45 182 034 19.3Other Midwife Obstetrics Unit 0.0 0.0 1 021 0.1

Special Clinic 0.7 5 768 0.1

PHC Service - - 223 0.0

Province - - 334 0.0

Total 0.2 5 2 346 0.2

Total 24.4 230 479 943 848 100.0

Figure 5: Caesarean section rate by level of care, by province, 2013/14

Prov District

0 20 40 60 80Indicator Value

0K 10K 20K 30K 40K 50K 60K 70KDenominator (number)

0% 20% 40% 60% 80% 100%% of denominator

EC A Nzo: DC44

Amathole: DC12

Buffalo City: BUF

C Hani: DC13

Cacadu: DC10

Joe Gqabi: DC14

N Mandela Bay: NMA

OR Tambo: DC15

FS Fezile Dabi: DC20

Lejweleputswa: DC18

Mangaung: MAN


Xhariep: DC16

GP Ekurhuleni: EKU

Johannesburg: JHB

Sedibeng: DC42

Tshwane: TSH

West Rand: DC48

KZN Amajuba: DC25

eThekwini: ETH

Harry Gwala: DC43

iLembe: DC29

Ugu: DC21

uMgungundlovu: DC22

uMkhanyakude: DC27

uMzinyathi: DC24

uThukela: DC23

uThungulu: DC28

Zululand: DC26

LP Capricorn: DC35

Gr Sekhukhune: DC47

Mopani: DC33

Vhembe: DC34

Waterberg: DC36

MP Ehlanzeni: DC32

G Sibande: DC30

Nkangala: DC31

NC Frances Baard: DC9

JT Gaetsewe: DC45

Namakwa: DC6

Pixley ka Seme: DC7

ZF Mgcawu: DC8

NW Bojanala: DC37

Dr K Kaunda: DC40

NM Molema: DC38

RS Mompati: DC39

WC Cape Town: CPT

Cape Winelands: DC2

Central Karoo: DC5

Eden: DC4

Overberg: DC3

West Coast: DC1

14.9

50.9

70.8

23.7

36.7

24.6

76.6

14.0

22.0

35.0

59.0

19.2

41.1

9.5

12,062

13,471

8,629

6,813

9,213

9,136

9,140

12.7%

25.6%

33.6%

92.2%

87.3%

14.8%

68.9%

96.0%

98.9%

15.0%

41.4%

31.1%

16.9%

59.7%

31.2%

28.3%

20.2%

9.4%

51.5

22.8

10.7

63.3

11.6

32.0

42.4

33.2

0.7

0.7

0.3

2.0

7,441

12.4%17.3%

64.9%

51.2%

32.0%

60.3%

96.9%

26.4%

41.0%

31.8%

35.2%

19.8 41.9

51.8

26.7

17.3

41.7

38.6

33.4

40.1

67.1

0.0

27,575

17,81830,789 16,023

15,833

13,183 13,042

11,761

8,737 8,304

6,932

6,681

19.0%

26.3%

24.3%

16.2%

14.3%

38.4%

25.5%

42.3%

44.5%

23.7%

35.0%

17.1%

43.4%

25.5%

13.0%

45.5%

25.7%

51.5

78.5

25.8

28.8

50.836.3

30.3

40.6

21.6

20.6

51.6

69.0

25.4

31.4

31.1

29.1

14,678

10,813

12,140

33,382

7,098

9,387

8,142

7,032

8,621

6,891

7,761

9,481

18.6%

10.6%

15.0%

12.5%

16.6%

96.7%

24.1%

63.0%

41.0%

81.4%

95.9%

41.0%

34.6%

89.2%

85.4%

59.2%

59.3%

21.0%

41.9%

44.6%

46.2%

9.3%

28.5

19.6

27.6

26.0

21.4

0.8

0.0

15,315

14,948

18,277

15,562

7,169

7,986

9,084

9,562

12.4%

23.5%

22.1%

16.6%

53.5%

58.6%

59.7%

56.4%

64.0%

30.6%

11.0%

15.9%

16.2%

32.5%

21.8

35.7

23.6

18.2

22,684

13,032

7,723

9,814

11.7%

29.2%

59.3%

72.8%

47.4%

20.2%

15.4%

12.7%

22.6%

24.9

24.9

21.0

13.4

56.28.7

0.1

39.5%

31.7%

41.2%

11.6%

12.6%

91.1%

68.3%

58.8%

28.3%60.1%

47.9%

24.5

21.7

51.3

23.6 41.0

44.0

21.4 39.1 7,235

7,299 15.2%

15.5%

10.0%

34.1%

25.2%

25.8%

33.5%

17.5%

13.3%

37.3%

42.2%

28.4%

61.5%

21.4%

14.3%

32.5 48.5

83.5

77.3

17.6

22.4

20.4

29.4

27.4

10,405 14,45318,520 19,664

4,965

1,097 100.0%

100.0%

31.2%

10.0%

22.9%

30.4%

58.2%

90.0%

29.4%

43.4%

32.5%

16.5%

15.9%

9.4%

Caesarean sect rate, by level of care, FY 2014

OrgUnitType (group)Clinic & Special ClinicCommunity Health CentreMidwife Obstetrics UnitOtherDistrict HospitalRegional HospitalProvincial Tertiary HospitalNational Central HospitalSpecialised HospitalsPrivate Hospital

83

Section A: Delivery

Figure 6: Caesarean section rate by level of care by district, 2013/14

Caesarean section rate (district hospitals) by NHI district, 2013/14

Percentage


Vhembe: DC34

G Sibande: DC30

uMzinyathi: DC24

Tshwane: TSH

Pixley ka Seme: DC7

Dr K Kaunda: DC40

OR Tambo: DC15

Eden: DC4

Amajuba: DC25

uMgungundlovu: DC22

10 20 30 40

22.0

10.7

20.6

31.1

20.6

22.9

18.8

19.8

21.0

21.4

22.6

SA average: 21.8


Caesarean section rate (district hospitals) by province, 2013/14


NC

FS

MP

EC

LP

GP

NW

WC

KZN

10 20 30 40

19.4

17.6

22.3

27.7

19.4

18.1

14.0

23.2

25.6

SA average: 21.8


84

Section A: Delivery

At district hospitals, on which the remainder of this section is based, the C-section rate increased from 20.8% in 2012/13 to 21.8% in 2013/14. This rate has increased steadily over the past decade by 5.6% on average each year. Provincially, the highest rate was in KwaZulu-Natal (27.7%) and the lowest was in the Northern Cape (14.0%) (see Figure 7).

The low C-section rate in NC remained largely unchanged over the past 10 years. Overall, the C-section rate at district hospitals increased in all the provinces in 2013/14, with the highest increase in the percentage of C-sections performed being in the North West, with an increase of 3.0 percentage points from 20.2% in 2012/13 to 23.2% in 2013/14. In Dr Kenneth Kaunda (NW) there was a 9.0 percentage point increase from 12.4% in 2012/13 to 21.4% in 2013/14. Over the past 10 years, the largest increase (10.2 percentage points on average) was in the Eastern Cape.

Figure 7: Delivery by Caesarean section rate by province, 2013/14

The province with highest proportion of total deliveries at district hospitals was Mpumalanga at 59.3% and the lowest was in Gauteng at 15.7%. At a district level, the West Coast (WC) and Central Karoo (WC) reported 100% of institutional deliveries at district hospitals. The lowest proportion of deliveries at district hospitals was reported in Johannesburg (4.5%, GP), Amajuba (7.5%, KZN), Ekurhuleni (7.7%, GP) and Frances Baard (12.6%, NC) (see Figure 8).

The highest C-section rate at district hospitals was in Nelson Mandela Bay at 41.1% (see Figure 8). This district has had the highest C-section rate in the country for the third year running. ZF Mgcawu (NC) again reported no C-sections at its two district hospitals that collectively recorded 1 109 deliveries. Xhariep (FS) reported no C-sections in 2012/13 but reported a rate of 2.0% in 2013/14.

In the NHI districts, the highest rate of 31.1% was in uMgungundlovu (KZN) and the lowest of 10.7% was in Thabo Mofutsanyana (FS). The greatest decrease was in West Rand (GP) with a 4.1 percentage point decline to 17.3%. In Cacadu (EC), the rate dropped by 3.1 percentage points to 24.6% and in uMzinyathi (KZN) by 2.5 percentage points to 20.6%.

The 10 hospitals with the highest C-section rates are listed in Table 2.

85

Section A: Delivery

Table 2: District hospitals with the highest delivery by Caesarean section rates, 2013/14

Facility name C-section rate Caesarean sections

(numerator)

Total deliveries (denominator)

Osindisweni Hospital (KZN – eThekwini) 49.2 934 1 900

Pongola Hospital (KZN – Zululand) 48.4 31 64

Khayelitsha Hospital (WC – Cape Town) 45.8 1 696 3 700

Wentworth Hospital (KZN – eThekwini) 43.5 1 025 2 355

Humansdorp Hospital (EC – Buffalo City) 43.3 784 1 811

Uitenhage Hospital (EC – Nelson Mandela Bay) 41.1 1 252 3 043

Murchison Hospital (KZN – Ugu) 39.3 1 138 2 894

Dr JS Moroka Hospital (FS – Mangaung) 38.4 434 1 130

Botshabelo Hospital (FS – Mangaung) 38.2 699 1 831

GJ Crooke’s Hospital (KZN – Ugu) 37.4 1 272 3 405

There were 42 out of 242 district hospitals (17.4%) where no C-sections were done yet deliveries took place. The majority of district hospitals had C-section rates between 10.0% and 29.9% (see Table 3).

Table 3: Delivery by Caesarean section rates at district hospitals, 2013/14

C-section rate Number of district hospitals % of district hospitals0.0 42 17.4

0.1 – 9.9% 19 7.9

10.0 – 19.9% 76 31.4

20.0 – 29.9% 74 30.6

30.0 – 39.9% 25 10.3

over 40.0% 6 2.5

Total 242 100

There were some data quality issues. Some district hospitals which regularly performed C-sections had at least one month of numerator data missing in 2013/14. The C-section rate is thus likely to be slightly higher than reported. Similar issues were observed at higher-level hospitals. Hospital classification concerns included 116 deliveries being reported at a specialised psychiatric hospital. There were 2 220 C-sections reported at one specialised TB hospital, King Dinuzulu Hospital.

Caesarean section rate (district hospitals) by district, 2013/14


ZF Mgcawu: DC8Xhariep: DC16

Frances Baard: DC9Joe Gqabi: DC14

T Mofutsanyana: DC19Lejweleputswa: DC18

JT Gaetsewe: DC45C Hani: DC13

Amathole: DC12Ehlanzeni: DC32

West Rand: DC48West Coast: DC1Nkangala: DC31Capricorn: DC35

Vhembe: DC34Mopani: DC33

A Nzo: DC44Sekhukhune: DC47

Ekurhuleni: EKUCape Winelands: DC2

G Sibande: DC30Overberg: DC3

uMzinyathi: DC24Tshwane: TSH

Pixley ka Seme: DC7Dr K Kaunda: DC40

uMkhanyakude: DC27RS Mompati: DC39

OR Tambo: DC15Waterberg: DC36

Central Karoo: DC5Eden: DC4

Fezile Dabi: DC20Amajuba: DC25uThukela: DC23Bojanala: DC37

Buffalo City: BUFNM Molema: DC38

Cacadu: DC10Namakwa: DC6Zululand: DC26

Harry Gwala: DC43Sedibeng: DC42

iLembe: DC29uThungulu: DC28

uMgungundlovu: DC22Mangaung: MANCape Town: CPT

Ugu: DC21Johannesburg: JHB

eThekwini: ETHN Mandela Bay: NMA

10 20 30 40

NHI

NHI

NHI

NHI

NHI

NHI

NHI

NHI

NHINHI

NHI

23.7

24.6

14.914.0

9.5

22.0

19.2

41.1

2.0

11.610.7

22.8

32.0

26.7

17.3

19.6

36.6

20.6

36.3

31.1

23.0

20.6

22.9

25.4

21.6

28.828.1

25.8

40.6

19.018.818.6

22.2

19.4

19.8

18.2

17.1

13.4

24.9

21.0

0.0

8.7

23.6

24.5

21.7

21.4

32.5

17.6

19.8

20.4

22.622.4

SA average: 21.8


86

Section A: Delivery

Figure 8: Delivery by Caesarean section rate by district, 2013/14

DC6

DC7

DC8

DC10

DC5

DC36

DC39

DC1

DC16

DC13

DC19DC18

DC30

DC4

DC2

DC38

DC32

DC45

DC14

DC34

DC12

DC35

DC20

DC33

DC37

DC31

DC3

DC9

DC26

DC40

DC27

DC47

DC15

DC23

DC44

DC43

DC22

DC24

DC28

TSH

MAN

DC25

TSH

DC42

DC48 EKUJHB

Gauteng

LegendProvince

District

CAESECR_DH_20132 - 13

14 - 20

21 - 24

25 - 31

32 - 41

87

Section A: Delivery

Map 2: Delivery by Caesarean section rate by district, 2013/14

Annual trends: Caesarean section rate (district hospitals)

Perc

enta

ge

0

10

20

30

40

EC FS

● ● ●●

● ●●

●

●

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0

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40

KZN

●●

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LP MP

0

10

20

30

40

2002

/03

2003

/04

2004

/05

2005

/06

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2007

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/13

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/14

NC

2002

/03

2003

/04

2004

/05

2005

/06

2006

/07

2007

/08

2008

/09

2009

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2010

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2011

/12

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/13

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/14

NW

2002

/03

2003

/04

2004

/05

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/06

2006

/07

2007

/08

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/09

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/10

2010

/11

2011

/12

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/13

2013

/14

●

● ●● ●

● ● ●●

● ●●

WC





●

●

●

88

Section A: Delivery

Figure 9: Annual trends: Delivery by Caesarean section rate

Annual trends: Caesarean section rate (district hospitals) by SEQ

Perc

enta

ge

0

10

20

30

40

2002

/03

2003

/04

2004

/05

2005

/06

2006

/07

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

2013

/14

SEQ 1

2002

/03

2003

/04

2004

/05

2005

/06

2006

/07

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

2013

/14

●

●

●

●

●

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●

●

●

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●

SEQ 2

2002

/03

2003

/04

2004

/05

2005

/06

2006

/07

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

2013

/14

SEQ 3

2002

/03

2003

/04

2004

/05

2005

/06

2006

/07

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

2013

/14

●

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●

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SEQ 4

2002

/03

2003

/04

2004

/05

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●

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SEQ 5





●

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89

Section A: Delivery

Figure 10: Delivery by Caesarean section rate by SEQ

Stillbirth rate in facility by NHI district, 2013/14

per 1 000 births

uMgungundlovu: DC22

Amajuba: DC25


Dr K Kaunda: DC40

OR Tambo: DC15

G Sibande: DC30

Pixley ka Seme: DC7

Tshwane: TSH

Eden: DC4

uMzinyathi: DC24

Vhembe: DC34

10 20 30

25.6

27.5

20.3

32.4

18.4

27.9

17.3

23.1

21.8

26.9

18.5SA average: 21.5


Stillbirth rate in facility by province, 2013/14

per 1 000 births [Source: DHIS]

FS

NC

NW

KZN

MP

LP

EC

GP

WC

10 20 30

20.6

27.4

20.2

23.2

21.1

21.3

26.1

23.5



90

Section A: Delivery

At DHB workshops conducted in 2013 and 2014, reasons for unnecessarily high C-section rates or inadequate availability of C-sections included:

✦ poor observation of women in labour and an inability of labour ward staff to interpret cardiotocography (CTG) tracing and the partogram;

✦ doctors delaying in attending to obstetric emergencies;

✦ a preference by doctors to perform C-sections rather than assisted deliveries. The skills to perform assisted deliveries have been lost or are being lost particularly as there is also a lack of advanced midwives who are trained to perform assisted deliveries. Unnecessary C-sections are being performed instead;g

✦ late first ANC bookings resulting in high-risk cases not being identified early;

✦ hospitals are doing more C-sections because Midwife Obstetric Units (MOUs) have a lack of advanced midwives able to perform assisted deliveries and able to assist with obstetric emergencies;h

✦ a high percentage of deliveries in facility under 18 years.

4.3 Stillbirth rate in facility

The stillbirth rate (SBR) is a good indicator of care during the third trimester and intrapartum period. It is therefore one of the key indicators for Maternal, Newborn, Child and Women’s Health (MNCWH) as it is a reflection of foetal, maternal and health system factors.

The stillbirth rate measures the number of babies who are born dead per 1 000 total births. Only the stillbirths that occur in health facilities are reported here, the majority being public health sector facilities along with a limited number of private hospitals and mobile clinics. Deaths outside of these services, such as in the community, are not taken into account.

A stillborn foetus might have been dead (in utero) for some time (macerated) or have died not long prior to delivery (fresh). The indicator does not differentiate between fresh and macerated stillbirths. Stillbirths should only be counted when the foetus is of 26 or more weeks’ gestational age and/or weighs 500g or more.

The national stillbirth rate was 21.5 deaths per 1 000 total births, representing a slight decrease from the 2012/13 rate of 21.8 per 1 000 total births. This was the lowest rate since 2001/02 but remained higher than the NDoH target of 19.7 per 1 000 total births. The rate was lowest in the Western Cape at 17.4 and highest in the Free State where there was an increase of 2.3 percentage points to 27.4 (after a decline from 29.1 to 25.1 in 2012/13). After being relatively stable for a few years at around 24 per 1 000 total births, Mpumalanga showed a decline of 3 percentage points to 21.3 per 1 000 total births. Over the past five years, Northern Cape has been the only province where the stillbirth rate has increased (4.4% average increase per year)

Figure 11: Stillbirth rate in facility by province, 2013/14

g Pattinson R. Reducing direct causes of maternal death. South African Journal of Obstetrics and Gynaecology. 2013;19(3):59-60. http://www.sajog.org.za/index.php/SAJOG/article/view/772/412

h Pattinson R. Reducing direct causes of maternal death. South African Journal of Obstetrics and Gynaecology. 2013;19(3):59-60. http://www.sajog.org.za/index.php/SAJOG/article/view/772/412

DC6

DC7

DC8

DC10

DC5

DC36

DC39

DC1

DC16

DC13

DC19DC18

DC30

DC4

DC2

DC38

DC32

DC45

DC14

DC34

DC12

DC35

DC20

DC33

DC37

DC31

DC3

DC9

DC26

DC40

DC27

DC47

DC15

DC23

DC44

DC43

DC22

DC24

DC28

TSH

MAN

DC25

TSH

DC42

DC48 EKUJHB

Gauteng

LegendProvince

District

SBR_201312 - 15

16 - 19

20 - 22

23 - 26

27 - 32

91

Section A: Delivery

At district level, there is a 2.7-fold difference between the best and the worst performing districts, with West Coast (WC) being the lowest at 11.9 stillbirths per 1 000 births and uMgungundlovu (KZN) being the highest at 32.4 per 1 000 total births (see Figure 12). uMgungundlovu was still seeing an overall increase in the stillbirth rate from a low of 21.9 in 2009/10. The rate in Pixley ka Seme (NC) increased again to 21.8 following a relatively low value of 13.2 in 2012/13. In Central Karoo (WC) the rate decreased to 19.9 per 1 000 total births following a peak of 33.5 per 1 000 total births in 2012/13.

Map 3: Stillbirth in facility rate by district, 2013/14

Stillbirth rate in facility by district, 2013/14

per 1 000 births [Source: DHIS]

uMgungundlovu: DC22Lejweleputswa: DC18

Amajuba: DC25Mangaung: MAN

JT Gaetsewe: DC45T Mofutsanyana: DC19

Frances Baard: DC9ZF Mgcawu: DC8

Dr K Kaunda: DC40RS Mompati: DC39

uThungulu: DC28OR Tambo: DC15Capricorn: DC35Nkangala: DC31

Ugu: DC21Fezile Dabi: DC20

uThukela: DC23Buffalo City: BUF

iLembe: DC29G Sibande: DC30

Sekhukhune: DC47Zululand: DC26eThekwini: ETH

Ekurhuleni: EKUPixley ka Seme: DC7

Bojanala: DC37NM Molema: DC38

Sedibeng: DC42Xhariep: DC16

Waterberg: DC36Namakwa: DC6Tshwane: TSHCacadu: DC10Mopani: DC33

Central Karoo: DC5Johannesburg: JHB

Ehlanzeni: DC32Eden: DC4

Cape Town: CPTuMzinyathi: DC24

Harry Gwala: DC43C Hani: DC13

N Mandela Bay: NMAVhembe: DC34

Amathole: DC12A Nzo: DC44

Joe Gqabi: DC14uMkhanyakude: DC27

West Rand: DC48Cape Winelands: DC2

Overberg: DC3West Coast: DC1

10 20 30

NHI

NHI

NHI

NHI

NHI

NHI

NHI

NHI

NHI

NHI

NHI

23.2

20.1

17.1

17.8

16.7

25.6

16.9

17.7

20.9

30.1

27.5

23.9

27.6

21.4

15.2

21.9

19.5

20.3

24.0

32.4

23.7

18.4

27.9

21.9

16.3

26.8

23.2

18.0

21.9

20.1

17.3

24.9

20.9

22.923.1

24.3

18.9

27.6

20.4

21.8

27.127.4

21.721.6

26.826.9

18.4

11.9

15.112.0

18.5

19.9

SA average: 21.5

Target: 19.7


92

Section A: Delivery

Figure 12: Stillbirth in facility rate by district, 2013/14

Annual trends: Stillbirth rate in facility

per 1

000

birt

hs

10

20

30

40

50

EC FS

●

●

●●

●

● ●

● ●● ● ●

GP

10

20

30

40

50

KZN

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●●

LP MP

10

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40

50

2002

/03

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NC

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/14

NW

2002

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● ●

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WC





●

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93

Section A: Delivery

Many districts still showed fluctuating trends, particularly those with less than 5 000 births per year (see Figure 13). In the NHI districts, the best performing district was Vhembe at 17.3 per 1 000 total births, with uMgungundlovu being 1.8-fold higher at 32.4 per 1 000 total births. The median stillbirth rate was lowest in the socio-economic Quintile 1 districts at 18.0 per 1 000 births in 2013/14.

Figure 13: Annual trends: Stillbirth in facility rate

Annual trends: Stillbirth rate in facility by SEQ

per 1

000

birt

hs

10

20

30

40

50

2002

/03

2003

/04

2004

/05

2005

/06

2006

/07

2007

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2008

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2009

/10

2010

/11

2011

/12

2012

/13

2013

/14

SEQ 1

2002

/03

2003

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2004

/05

2005

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2006

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SEQ 5





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94

Section A: Delivery

Figure 14: Stillbirth in facility rate by SEQ

95

Section A: Delivery

At DHB workshops conducted in 2013 and 2014, challenges to reducing the stillbirth rate were identified as follows:

Patient-related factors:

✦ cultural practices;

✦ traditional and over-the-counter medication both during pregnancy and those taken to induce labour;

✦ delay in seeking medical attention;

✦ pre-existing maternal conditions (often unrecognised or not disclosed);

✦ poor response to reduced foetal movements;

✦ no antenatal attendance;

✦ late booking: women typically do not book until showing;

✦ lack of health education;

Administrative factors:

✦ insufficient staff allocation to labour wards;

✦ delay in ambulance response time;

✦ lack of equipment such as CTG machines;

Healthcare Worker related factors:

✦ inability to interpret CTG tracing and partogram;

✦ delay in response to poor foetal condition;

✦ doctors delaying in attending to obstetric emergencies.

The stillbirth rate, although slowly declining, was still higher than the target. Ongoing efforts to improve antenatal and intrapartum care are required.

4.4 Inpatient early neonatal death rate in facility

The inpatient early neonatal death rate measures the number of deaths of live born babies that occur within 7 completed days after birth per 1 000 live births. It includes only neonatal deaths when the foetus is of 26 or more weeks’ gestational age and/or weighs 500g or more. The deaths reported in this chapter occur predominantly in public health facilities but include a limited number of private hospitals. Deaths occurring at home are not included.

The inpatient early neonatal mortality rate provides an indication of the quality of antenatal, intrapartum and postnatal care. It is also a significant contributor to the under-five mortality rate (Millennium development Goal 4A: reduce by two thirds, between 1990 and 2015, the under-five mortality rate). It is therefore a key indicator to address in order for South Africa to meet its targets.

The 2013/14 inpatient early neonatal death rate was 10.1 per 1 000 live births, a marginal decrease from 10.2 in 2012/13. This was lower than the NDoH target of 10.9. Provincially, this was lowest in the Western Cape at 4.8 and 2.9-fold higher in the Eastern Cape at 14.1 (see Figure 15). Decreases were seen in the Eastern Cape (2.3 percentage points), Mpumalanga (0.9 percentage points), North West (0.9 percentage points) and the Western Cape (1.4 percentage points). Increases were seen in the other provinces, with the greatest increase (1.7 percentage points) in KwaZulu-Natal.

Inpatient early neonatal death rate by NHI district, 2013/14

per 1 000 live births

Dr K Kaunda: DC40

OR Tambo: DC15

uMgungundlovu: DC22


Pixley ka Seme: DC7

uMzinyathi: DC24

G Sibande: DC30

Amajuba: DC25

Tshwane: TSH

Vhembe: DC34

Eden: DC4

5 10 15 20 25

13.3

12.9

8.2

13.2

11.4

9.2

8.0

9.8

11.5

16.2

6.5

SA average: 10.1


Inpatient early neonatal death rate by province, 2013/14

per 1 000 live births [Source: DHIS]

EC

NC

FS

LP

KZN

NW

GP

MP

WC

5 10 15 20 25

14.1

12.3

9.3

10.4

11.7

8.6

12.8

9.5

4.8SA average: 10.1


DC6

DC7

DC8

DC10

DC5

DC36

DC39

DC1

DC16

DC13

DC19DC18

DC30

DC4

DC2

DC38

DC32

DC45

DC14

DC34

DC12

DC35

DC20

DC33

DC37

DC31

DC3

DC9

DC26

DC40

DC27

DC47

DC15

DC23

DC44

DC43

DC22

DC24

DC28

TSH

MAN

DC25

TSH

DC42

DC48 EKUJHB

Gauteng

LegendProvince

District

ENDR_20133.3 - 4.7

4.8 - 8.8

8.9 - 11.8

11.9 - 17.9

18.0 - 25.7

96

Section A: Delivery

Figure 15: Inpatient early neonatal death rate by province, 2013/14

Nelson Mandela Bay had the highest inpatient early neonatal death rate at 25.7 deaths per 1 000 live births (see Figure 16), although this district’s stillbirth rate was among the lowest. This may indicate poor intrapartum and postnatal care. The lowest inpatient early neonatal death rate was in the Cape Winelands (WC). In the NHI districts, there was a 2.5 fold difference between Eden (WC), the best performing district, with 6.5 deaths per 1 000 live births and Dr Kenneth Kaunda (NW) with 16.2 deaths per 1 000 live births.

Map 4: Inpatient early neonatal death rate by district, 2013/14

Inpatient early neonatal death rate by district, 2013/14


N Mandela Bay: NMAZF Mgcawu: DC8Capricorn: DC35

Dr K Kaunda: DC40uThungulu: DC28

Lejweleputswa: DC18Harry Gwala: DC43

OR Tambo: DC15uMgungundlovu: DC22T Mofutsanyana: DC19

Buffalo City: BUFC Hani: DC13

Fezile Dabi: DC20Namakwa: DC6

iLembe: DC29Pixley ka Seme: DC7

uMzinyathi: DC24Mopani: DC33

Frances Baard: DC9Waterberg: DC36Amathole: DC12

Sekhukhune: DC47Mangaung: MANEkurhuleni: EKU

Ugu: DC21Johannesburg: JHBJT Gaetsewe: DC45

eThekwini: ETHG Sibande: DC30

Overberg: DC3A Nzo: DC44

Joe Gqabi: DC14Amajuba: DC25uThukela: DC23

NM Molema: DC38Xhariep: DC16

Ehlanzeni: DC32Tshwane: TSH

RS Mompati: DC39Vhembe: DC34

Sedibeng: DC42Zululand: DC26

Nkangala: DC31West Rand: DC48

Bojanala: DC37Cacadu: DC10

Eden: DC4Central Karoo: DC5

Cape Town: CPTuMkhanyakude: DC27

West Coast: DC1Cape Winelands: DC2

5 10 15 20 25

NHI

NHI

NHI

NHI

NHI

NHI

NHI

NHI

NHI

NHI

NHI

12.8

6.7

10.4

12.5

9.3

13.3

9.5

25.7

8.8

14.8

12.9

12.4

10.2

8.0

7.2

10.2

10.0

8.2

10.1

13.2

9.0

11.4

9.2

7.6

4.0

14.9

11.8

14.4

9.8

11.2

8.0

17.9

10.9

10.3

9.8

7.3

8.7

9.9

12.2

11.5

21.4

11.2

6.8

9.0

8.1

16.2

4.7

3.9 3.3

9.6

6.5 6.5

SA average: 10.1

Target: 10.9


97

Section A: Delivery

Figure 16: Inpatient early neonatal death rate by district, 2013/14

Annual trends: Inpatient early neonatal death rate

per 1

000

live

birt

hs

0

5

10

15

20

25

EC FS

●● ●

●●

●

● ●

● ●

●

●

GP

0

5

10

15

20

25

KZN

●● ●

●

●

● ●

● ● ● ●●

LP MP

0

5

10

15

20

25

2002

/03

2003

/04

2004

/05

2005

/06

2006

/07

2007

/08

2008

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2009

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2010

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2011

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2012

/13

2013

/14

NC

2002

/03

2003

/04

2004

/05

2005

/06

2006

/07

2007

/08

2008

/09

2009

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2010

/11

2011

/12

2012

/13

2013

/14

NW

2002

/03

2003

/04

2004

/05

2005

/06

2006

/07

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

2013

/14

● ●

●●

●

●

●

●

●●

●●

WC





●

●

●

98

Section A: Delivery

In terms of annual trends (see Figure 17), the greatest decreases were seen in OR Tambo (EC) (-7.0 percentage points), Central Karoo (NC) (-6.6 percentage points) and Frances Baard (NC) (-5.4 percentage points). The greatest increases were seen in ZF Mgcawu (NC) (13.4 percentage points), Amajuba (KZN) (6.3 percentage points) and Xhariep (FS) (5.1 percentage points).

Figure 17: Annual trends: Inpatient early neonatal death rate

Annual trends: Inpatient early neonatal death rate by SEQ

per 1

000

live

birt

hs

0

5

10

15

20

25

2002

/03

2003

/04

2004

/05

2005

/06

2006

/07

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

2013

/14

SEQ 1

2002

/03

2003

/04

2004

/05

2005

/06

2006

/07

2007

/08

2008

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2009

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2010

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2011

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2012

/13

2013

/14

●

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SEQ 2

2002

/03

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2004

/05

2005

/06

2006

/07

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

2013

/14

SEQ 3

2002

/03

2003

/04

2004

/05

2005

/06

2006

/07

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

2013

/14

●

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●

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●

SEQ 4

2002

/03

2003

/04

2004

/05

2005

/06

2006

/07

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

2013

/14

●

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●

●

●

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● ●

●

●

SEQ 5





●

●

●

99

Section A: Delivery

Figure 18: Inpatient early neonatal death rate by SEQ

100

Section A: Delivery

The early neonatal death rate remained high in certain facilities and districts. This may have been due to inadequate care provided at the facility or may be indicative of poor service delivery at lower levels of care within that district. It may also be indicative of broader issues such as delays in referral to facilities able to provide care to neonates.

At DHB workshops conducted in 2013 and 2014, reasons suggested for poor performance included:

✦ late presentation to facility both for antenatal care and in labour with high-risk cases not identified in time;

✦ poor quality of antenatal care;

✦ lack of essential equipment, e.g. incubators;

✦ cultural influence;

✦ a higher portion of delivery under 18 years as the newborn babies are premature or have a birth weight of less than 2 500g.

While overall the inpatient early neonatal death rate was slowly improving, certain districts and facilities still had very high rates. Districts with rates far above the average were: Nelson Mandela Bay (EC) and ZF Mgcawu (NC). Capricorn (LP), Dr Kenneth Kaunda (NW), uThungulu (KZN) and Lejweleputswa (FS) were above the district average.

Districts with the highest numbers of early neonatal deaths were: Johannesburg (GP), Ekurhuleni (GP), eThekwini (KZN), Nelson Mandela Bay (EC) and Capricorn (LP). A substantial reduction of the early neonatal deaths in these districts will have a big impact on the country’s overall performance for this indicator.

4.5 Maternal mortality ratio in facility

“Maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. To facilitate the identification of maternal deaths in circumstances in which cause of death attribution is inadequate, a new category has been introduced: Pregnancy-related death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death.” In other words, any death whilst the woman is pregnant up to seven weeks post-partum is included in the definition. The maternal mortality ratio (MMR) is the number of maternal deaths per 100 000 live births.i

The NIDS stipulates that these deaths should occur while in a health facility in order to calculate the maternal mortality ratio in facility.

According to Millennium Development Goal 5, South Africa should aim to reduce the MMR by three quarters between 1990 and 2015. The reduction of the MMR is a priority area of the Negotiated Service Delivery Agreement (NSDA) and a key component of the Strategic Plan for Maternal, Neonatal, Child and Women’s Health (MNCWH) and Nutrition in South Africa 2011–2016. South Africa has adopted the Campaign on Accelerated Reduction of Maternal and Child Mortality in Africa (CARMMA) strategy, and action components of this strategy mirror key priorities outlined in the Strategic Plan for MNCWH.

The most recent report from the National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD) reports that bleeding during or after Caesarean section was the cause for almost a third of maternal deaths due to obstetric haemorrhage for 2011 and 2012 combined. Maternal deaths due to bleeding during or after Caesarean section increased in 2012 to 35.3% compared with 27.5% in 2011. Non-pregnancy related infections, obstetric haemorrhage and hypertension contributed 26.0%, 23.8% and 16.5% of the avoidable deaths respectively.j

The MMR can be calculated in various ways. The population-based MMR is estimated from the vital registration system and includes all registered maternal deaths regardless of the place of death.k The facility-based MMR measures maternal deaths occurring in health facilities, primarily in the public sector, and can be calculated from two sources, namely the District Health Information Software (DHIS) and the NCCEMD. Historically, the NCCEMD MMR values have been higher than those in the DHIS in most geographical areas, presumably because the NCCEMD is a well-established system with a strong regulatory framework. However, the values from the two systems are now approximating each other, so much more reliance can now be placed on the DHIS. DHIS data are available monthly, whereas the NCCEMD is published every three years with a time-lag. With DHIS information being available more timeously and with disaggregation to facility level, it may become a better method of monitoring progress, especially as these data have been reaching completeness since 2012/13. Maternal mortality is a relatively rare event and, therefore, year-one-year fluctuations, especially in districts with low numbers of live births or small populations, must be treated with caution until there is a much longer time series of data available.

i World Health Organization. Maternal mortality ratio (per 100 000 live births) http://www.who.int/healthinfo/statistics/indmaternalmortality/en/

j Pattinson R, Fawcus S, Moodley J. Tenth interim report on Confidential Enquiries into Maternal Deaths in South Africa 2011 and 2012. Pretoria: National Department of Health, 2013.

k Bradshaw D, Dorrington R, Laubscher R. Rapid Mortality Surveillance Report 2011. Cape Town: Medical Research Council; 2012.

Maternal mortality in facility ratio by NHI district, 2013/14

per 100 000 live births

Dr K Kaunda: DC40

OR Tambo: DC15

uMgungundlovu: DC22

G Sibande: DC30


Vhembe: DC34

Amajuba: DC25

Eden: DC4

uMzinyathi: DC24

Pixley ka Seme: DC7

Tshwane: TSH

100 200 300

229.7

123.3

63.3

208.3

71.6

109.8

111.2

197.1

67.6

257.4

105.4SA average: 133.3 Provinces

ECFSGPKZNLPMPNCNWWC

Maternal mortality in facility ratio by province, 2013/14


NW

EC

LP

MP

KZN

FS

NC

GP

WC

100 200 300

156.2

143.4

104.5

148.4

152.0

149.1

118.9

184.9



101

Section A: Delivery

In 2013/14, there was a marginal increase in the facility MMR from 132.9 to 133.3 per 100 000 live births. There were 1 249 maternal deaths from 937 082 live births. Provincially, the facility MMR in the DHIS for 2013/14 ranged from 68.6 per 100 000 live births in the Western Cape to 184.9 per 100 000 live births in the North West (see Figure 19). Four provinces showed increases in their maternal deaths: Eastern Cape, Free State, North West and the Western Cape. In the Free State, the absolute number of maternal deaths remained stable at 64 but the total number of live births reported was less than that in 2012/13. The remaining five provinces all showed a decrease.

In comparison, the 2010 MMR from the NCCEMD data was 182.8 deaths per 100 000 live births; in 2011 it was 165.6 and in 2012 it was 151.7 deaths per 100 000 live births. Provincially it was reported to be highest in 2012 in Limpopo (185.8) and lowest in the Western Cape (82.0).

Figure 19: Maternal mortality in facility ratio by province, 2013/14

The facility MMR recorded in the DHIS by district (Figure 20) ranged from 35.5 deaths per 100 000 live births in the Cape Winelands (WC) to 353.7 per 100 000 live births in Capricorn (LP). Capricorn also had the highest MMR in 2011/12 and 2012/13, and had the third highest MMR in 2012 according to the NCCEMD data. The MMR increased from 292.2 in 2012/13 to 353.7 deaths per 100 000 live births in 2013/14 in this district. Two districts reported no maternal deaths, namely Central Karoo (WC) and Xhariep (FS), probably due to a combination of a low number of births and their complicated deliveries being transferred to hospitals in other districts.

Four of the 11 NHI districts had facility MMR above the national average, with Dr Kenneth Kaunda (NW) having the highest MMR of the NHI sites and the second highest facility MMR in the country at 257.4 per 100 000 live births. Tshwane (GP) had the lowest MMR of the NHI sites and the sixth lowest in the country.

When comparing absolute numbers of maternal deaths, they were highest in Ekurhuleni (MP), Capricorn (LP) and eThekwini (KZN) (see Table 6).

DC6

DC7

DC8

DC10

DC5

DC36

DC39

DC1

DC16

DC13

DC19DC18

DC30

DC4

DC2

DC38

DC32

DC45

DC14

DC34

DC12

DC35

DC20

DC33

DC37

DC31

DC3

DC9

DC26

DC40

DC27

DC47

DC15

DC23

DC44

DC43

DC22

DC24

DC28

TSH

MAN

DC25

TSH

DC42

DC48 EKUJHB

Gauteng

LegendProvince

District

MATMORTR_201336 - 74

75 - 105

106 - 148

149 - 230

231 - 354

102

Section A: Delivery

Table 6: Highest absolute number of maternal deaths (district level), 2013/14

District Maternal deaths Live births MMREkurhuleni (MP) 102 61 501 165.9

Capricorn (LP) 98 27 706 353.7

eThekwini (KZN) 97 55 604 174.4

OR Tambo (EC) 74 32 220 229.7

Johannesburg (GP) 50 64 988 76.9

Map 5: Maternal mortality in facility ratio by district, 2013/14

Maternal mortality in facility ratio by district, 2013/14


Capricorn: DC35Dr K Kaunda: DC40

OR Tambo: DC15uMgungundlovu: DC22

NM Molema: DC38G Sibande: DC30

iLembe: DC29Lejweleputswa: DC18

uThungulu: DC28Frances Baard: DC9

eThekwini: ETHC Hani: DC13

Ekurhuleni: EKUUgu: DC21

Bojanala: DC37Nkangala: DC31Mangaung: MANBuffalo City: BUF

N Mandela Bay: NMAT Mofutsanyana: DC19

Zululand: DC26A Nzo: DC44

uThukela: DC23Ehlanzeni: DC32Sedibeng: DC42

Cacadu: DC10Waterberg: DC36

Fezile Dabi: DC20Vhembe: DC34

RS Mompati: DC39Amajuba: DC25

Eden: DC4Joe Gqabi: DC14

Mopani: DC33West Rand: DC48

JT Gaetsewe: DC45Amathole: DC12

Harry Gwala: DC43ZF Mgcawu: DC8

Johannesburg: JHBCape Town: CPT

uMzinyathi: DC24Pixley ka Seme: DC7

Overberg: DC3Tshwane: TSH

Sekhukhune: DC47Namakwa: DC6

uMkhanyakude: DC27West Coast: DC1

Cape Winelands: DC2Central Karoo: DC5

Xhariep: DC16

100 200 300

NHI

NHI

NHI

NHI

NHI

NHI

NHI

NHI

NHI

NHI

NHI

133.3

121.7

86.3

168.5

105.2

229.7

123.2

132.9

0.0

192.2

123.3

117.8

148.4

122.5

94.4

165.9

76.9

63.3

161.0

208.3

123.0

71.6

109.8

123.3

53.6

186.6

194.1

84.0

174.4

95.7

111.2

353.7

121.4

61.8

197.1

156.1

123.0

93.2

61.2

67.6

78.2

186.0

160.5

206.9

110.7

257.4

74.2

38.9 35.5

63.9

105.4

0.0 SA average: 133.3


103

Section A: Delivery

Figure 20: Maternal mortality in facility ratio by district, 2013/14

Annual trends: Maternal mortality in facility ratio

per 1

00 0

00 li

ve b

irths

0

100

200

300

400

500

600EC FS

●●

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GP

0

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400

500

600KZN

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●

LP MP

0

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600

2007

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2008

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2007

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2009

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2010

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2011

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2012

/13

2013

/14

● ●

●

WC





●

●

●

104

Section A: Delivery

Figure 21: Annual trends: Maternal mortality in facility ratio

Annual trends: Maternal mortality in facility ratio by SEQ

per 1

00 0

00 li

ve b

irths

0

100

200

300

400

500

60020

07/0

820

08/0

920

09/1

020

10/1

120

11/1

220

12/1

320

13/1

4

SEQ 1

2007

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SEQ 5





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105

Section A: Delivery

Figure 22: Maternal mortality in facility ratio by SEQ

106

Section A: Delivery

There is an association between districts with a high HIV prevalence according to the 2012 Antenatal Sero-prevalence Survey and those with a high MMR in 2013/14, as can be seen in Figure 23. There was no apparent association with TB incidence (all types).

Figure 23: Scatterplot of maternal mortality in facility ratio versus HIV prevalence and TB incidence (all types) by district, 2013/14

When comparing the stillbirth rate and early neonatal death rate, these were also high in districts with a high MMR (see Figure 24).

There is also an association with a high MMR in facilities where a high number of C-sections are done. This applies to all facilities and does not hold true when looking only at district hospitals.

107

Section A: Delivery

Figure 24: Scatterplot of maternal mortality in facility ratio versus SBR and ENDR by district, 2013/14

At DHB workshops conducted in 2013 and 2014, reasons for poor performance included:

✦ bleeding after C-section is not well managed and additional skills are needed;

✦ blood for transfusions is not always readily available;

✦ Emergency Medical Services are not readily available for inter-facility transport of patients;

✦ South Africa is a multicultural environment with many traditional beliefs and traditional healers. Patients use a concoction to induce labour that wears off but contributes to maternal and foetal fatigue;

✦ dishonesty among patients who “lose their maternal record” so that high-risk women not easily identified;

✦ patients with unrecognised chronic conditions;

✦ late or no booking;

✦ insufficient staff allocated to labour wards;

✦ failure of staff to recognise complications;

✦ poor compliance with protocols;

✦ inadequate leadership and supervision;

✦ wards (especially labour wards) supplemented by nursing students who are inexperienced and are left to manage women on their own;

✦ nursing unit heads should be seeing all patients but are not doing so and are not aware of which patients are in labour;

✦ compulsory rotation of staff through various specialities in the facility at regular intervals can be problematic as this results in not having expert and passionate nursing staff working in labour ward;

✦ receiving hospitals often only have junior doctors.

It is clear that action should be taken to address the direct and avoidable causes of obstetric deaths in order to continue to see a decline in the MMR.

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