CARDIOVASCULAR JOURNAL OF AFRICA • Vol 22, No 1, January/February 2011
AFRICA
31
Maternal deaths associated with hypertension in South
Africa: lessons to learn from the Saving Mothers report,
2005–2007
J MOODLEY, for the National Committee on Confidential Enquiries into Maternal Deaths, National Department of
Health, South Africa
Summary
From 2005–2007, there were 622 deaths associated with
hypertensive disorders of pregnancy. Eclampsia was the
major cause of death (
n
=
344; 55.3%). There were 173
(28.3%) deaths due to pre-eclampsia, and 38 (6.1%) associ-
ated with chronic hypertension. Cerebral complications were
the final cause of death in 283 (45.5%), while cardiac failure
and respiratory failure were the final causes in 142 (22.8%)
and 158 (25.4%), respectively.
Major problems were identified in all areas of assess-
ment. Non-attendance for antenatal care (
n
=
106; 19.4%)
and delay in seeking help (
n
=
106; 19.4%) were major
patient-related factors. Communication problems (
n
=
63;
10.8%) and lack of facilities (
n
=
50; 8.5%) were health
administration issues. Health worker-avoidable factors
included problem recognition, delay in referral and manage-
ment at an inappropriate level of healthcare.
Compared to the previous report of 2002–2004, there was
a reduction in deaths due to hypertension.
Keywords:
audit, maternal mortality, hypertension, lessons to
learn
Submitted 18/12/09, accepted 3/4/10
Cardiovasc J Afr
2011;
22
: 31–35
DOI: CVJ-21.026
Hypertensive disorders of pregnancy (HDP) are not only the
commonest medical complication in pregnancy, but remain the
commonest direct cause of maternal mortality in South Africa.
In the United Kingdom, despite the fact that maternal deaths
are uncommon, hypertensive deaths are the second common-
est cause after thrombo-embolism.
1
The latest Saving Mothers
report (2005–2007) indicates that there were 622 maternal deaths
from hypertensive disorders, virtually the same as in the previ-
ous report of 2002–2004.
2.3
The number of deaths reported in the
two previous Saving Mothers reports were 1999–2001:
n
=
507
4
and 2002–2004:
n
=
628.
3
The difference in numbers between
the first two reports probably indicated under-reporting in the
triennium 1999–2001. The two most recent reports, 2002–2004
3
and 2005–2007,
4
provide a better reflection of the numbers of
maternal deaths from HDP.
All maternal deaths in South Africa are notifiable to the
Department of Health and are reported in a structured data form
called the Maternal Death Notification Form, which contains
demographic data and clinical details surrounding the primary
and secondary causes of death. This form, together with a copy
of the hospital records, is sent to the provincial Maternal, Women
and Child Cluster who in turn, get an experienced maternal
health specialist and a midwife (trained assessors) to formulate
a confidential opinion on any substandard care based on patient-
related, administrative, and health personnel-related factors. All
assessments are collated every three years and published as the
Saving Mothers report. Recommendations to reduce maternal
deaths are also included in this report.
Causes of maternal deaths in South Africa
The primary causes of deaths in the various sub-categories of
hypertensive disorders are shown in Table 1. The primary causes
are similar to the 2002–2004 report.
3
The numbers of deaths
assigned to the HELLP syndrome declined in the latest report;
54 compared to 70 in the 2002–2004 report.
There was a small decline in the number of deaths from
cerebral complications, from 316 (2002–2004) to 283 patients.
Nonetheless, deaths from cerebrovascular events are a serious
concern. Guidelines for the treatment of hypertension associated
with severe pre-eclampsia and eclampsia are provided by the
National Health Department. Deaths from intracranial haemor-
rhage probably indicate inadequate treatment of severe hyperten-
sion or patient delay in seeking help. In the latest Why Women
Die (confidential enquiry into maternal deaths in the UK, 2003–
2005),
1
the single major failing in clinical care in pre-eclampsia
was inadequate treatment of sustained systolic hypertension.
There was an increase in the number of deaths from cardiac
failure as shown in Table 2. On the other hand, deaths from
renal failure have continued to decline through the three Saving
Mothers reports: 1999–2001 (
n
=
90; 17.8%), 2002–2004 (
n
=
Women’s Health and HIV Research Group, Nelson R
Mandela School of Medicine, University of KwaZulu-Natal,
Durban, South Africa
J MOODLEY, MB ChB,
TABLE 1. PRIMARY OBSTETRIC CAUSES OF DEATH IN
THE SUB-CATEGORIES
2005–2007
2002–2004
Sub-categories
n
%
n
%
chronic hypertension
38 6.1
37
5.9
proteinuric hypertension
173 27.8
171 27.2
eclampsia
344 55.3
347 55.3
HELLP syndrome
54 8.7
70 11.1
rupture of the liver
10 1.6
3
0.5
acute fatty liver
3 0.48
0
0.0
Total
622
628
