Cardiovascular Journal of Africa: Vol 27 No 2 (March/April 2016)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 2, March/April 2016 60 AFRICA
Cardiovascular Topics
The importance of cardiovascular pathology contributing
to maternal death: Confidential Enquiry into Maternal
Deaths in South Africa, 2011–2013
Priya Soma-Pillay, Joseph Seabe, Karen Sliwa
Abstract
Aims: Cardiac disease is emerging as an important contribu-
tor 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.
Methods: Data 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 record-
ed, as per statutory requirement. One hundred and sixty-nine
cases were reported for this period, with 118 complete hospi-
tal case files available for assessment and data analysis.
Results: Peripartum 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%).
Conclusion: The pattern of CVD contributing to maternal
death in South Africa was dominated by PPCM and compli-
cations 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 appropri-
ate 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.
Keywords: cardiac disease in pregnancy, valve disease, valve
thrombosis, rheumatic heart disease, cardiomyopathy, peripar-
tum cardiomyopathy
Submitted 31/8/15, accepted 1/2/16
Published online 19/2/16
Cardiovasc J Afr 2016; 27: 60–65
DOI: 10.5830/CVJA-2016-008
Cardiac disease is emerging as an important indirect cause of
maternal death globally. Cardiac conditions may be pre-existing,
such as rheumatic heart disease (RHD) or congenital heart
disease and may be unmasked by the increased haemodynamic
load in pregnancy, or may be caused by the pregnancy, for
example hypertensive disorders or peripartum cardiomyopathy
(PPCM).1
Compared with child mortality, maternal mortality has been
more difficult to track over time at a national level, in particular
in middle- to lower-income countries (LMICs). Major challenges
include incomplete data sets, inexperience of the physicians in
applying the classifications, misclassification of maternal deaths
to other causes in countries with complete vital registration and
Department of Obstetrics and Gynaecology, Maternal and
Foetal Medicine, University of Pretoria and Steve Biko
Academic Hospital, Pretoria, South Africa
Priya Soma-Pillay, MB ChB, MMed (O et G) Pret, FCOG, Cert
(Maternal and Foetal Med) SA,
Department of Obstetrics and Gynaecology, Tembisa
Hospital, Tembisa, South Africa
Joseph Seabe, MD
National Committee for the Confidential Enquiry into
Maternal Deaths, South Africa
Priya Soma-Pillay, MB ChB, MMed (O et G) Pret, FCOG, Cert
(Maternal and Foetal Med) SA
Joseph Seabe, MD
Hatter Institute for Cardiovascular Research in Africa, and
IDM, Department of Medicine, Faculty of Health Sciences,
University of Cape Town, South Africa; Soweto Cardiovascular
Research Unit, University of the Witwatersrand,
Johannesburg; Inter-Cape Heart Group, Medical Research
Council South Africa, Cape Town, South Africa
Karen Sliwa, MD, PhD, FESC,