Health – Child­birth mor­tal­ity

From South Africa to the US, the num­bers of black women dy­ing dur­ing preg­nancy and child­birth con­tinue to out­strip other groups. Why? And what can we do to help change this?


It was ten­nis ace Ser­ena Wil­liams’ fright­en­ing ex­pe­ri­ence in child­birth that put the ques­tion of black women dy­ing in preg­nancy on cen­tre court, as it were. In­ter­viewed by Vogue, Ser­ena told of hav­ing to self-di­ag­nose a lifethreat­en­ing emer­gency and talk her doc­tors through sav­ing her, af­ter she gave birth to daugh­ter Alexis last Septem­ber. Ser­ena had a his­tory of blood clots, and when she be­gan hav­ing breath­ing dif­fi­cul­ties, “she told the near­est nurse, be­tween gasps, that she needed a CT scan (a com­puter im­age of her chest) and in­tra­venous hep­arin (a blood thin­ner) right away”, Vogue re­ported. The scan showed sev­eral clots in her lungs.

“We have a lot of work to do as a na­tion and I hope my story can in­spire a con­ver­sa­tion that gets us to close this gap,” Ser­ena wrote on Face­book. “Ev­ery mother, re­gard­less of race or back­ground, de­serves to have a healthy preg­nancy and child­birth.”

Glob­ally, the num­ber of ma­ter­nal deaths to­day is low and drop­ping in most high-in­come coun­tries – but in the USA num­bers have more than dou­bled since 1987, giv­ing it what the World Health Or­gan­i­sa­tion re­ports is one of the high­est rates of ma­ter­nal deaths in the de­vel­oped world.

Ac­cord­ing to the Cen­ters for Dis­ease Con­trol (CDC), black women in the US are dy­ing at three to four times the rate of white women in preg­nancy or from causes re­lated to child­birth – and half those deaths may be pre­ventable. In a study of five med­i­cal com­pli­ca­tions that com­monly cause ma­ter­nal death or in­jury, black women were nearly three times more likely to die than white women with the same com­pli­ca­tions.

When it comes to Africa, the pic­ture is even bleaker. Women in sub-Sa­ha­ran Africa have the high­est ma­ter­nal mor­tal­ity ra­tio in the world, ac­count­ing for 66% of all deaths. Nearly 550 women die for ev­ery 100 000 ba­bies born. This, against a global ma­ter­nal mor­tal­ity ra­tio that has dropped 44% from 1990 to 2015, ac­cord­ing to a re­port by United Na­tions agen­cies and the World Bank Group – from 385 to 216 deaths for ev­ery 100 000 live births.

In that same 15-year pe­riod, South Africa’s ma­ter­nal mor­tal­ity rate ac­tu­ally rose – from 150 to 269 for ev­ery 100 000 live births. And most of the women dy­ing are black.


The rea­sons, it seems, are deeply rooted in the in­equal­i­ties of our so­ci­ety. A 2016 study called Grow­ing In­equities in Ma­ter­nal Health in South Africa, com­pared ac­cess to ma­ter­nal health ser­vices and health out­comes be­tween 2008 and 2012, and found in­equal­i­ties be­tween so­cio-eco­nomic groups (and there­fore race groups) had grown worse in key ar­eas linked to ma­ter­nal deaths:

An­te­na­tal clinic at­ten­dance dropped from 97% to 90%, es­pe­cially among the youngest and poor­est women with the low­est ed­u­ca­tion lev­els – “those liv­ing in ru­ral and ur­ban in­for­mal ar­eas, and black African women”, the re­searchers said.

Skilled birth at­ten­dance stayed around 95%, but in­equal­i­ties wors­ened and the gaps be­tween race groups grew: 90% of white and In­dian women had a doc­tor present in 2012, while for black African women, these lev­els only in­creased marginally (from 23.5% in 2008 to 28.4% in 2012) Planned preg­nan­cies fell from 44.6% to 34.7%: just 22% of the poor­est women had a planned preg­nancy in 2012, and among women younger than 20, just 8.7% of preg­nan­cies were planned, while school­girls and stu­dents ac­counted for 9.8% of all preg­nan­cies – an in­crease from 7.7% in 2008.

HIV test­ing rose, but re­mained low in groups with high HIV preva­lence, such as women in ru­ral ar­eas. The re­searchers (from the Hu­man Sci­ences Re­search Unit, Wits Re­pro­duc­tive Health and HIV In­sti­tute (RHI), Ev­i­dence Based So­lu­tions in Cape Town, and the De­part­ment of Psy­chi­a­try and Men­tal Health at UCT) found that “the wealth­i­est 10% of the pop­u­la­tion ac­counts for more than half the coun­try’s in­come, and in­dices of health, and es­pe­cially of ma­ter­nal health, clearly re­flect the in­equal­i­ties in ac­cess and health out­comes.” They noted that

although the

rise in ma­ter­nal mor­tal­ity from the late 1990s linked to the HIV/Aids epi­demic had dropped dra­mat­i­cally, es­pe­cially among preg­nant women, ma­ter­nal deaths from bleed­ing in preg­nancy and child­birth (haem­or­rhage) had in fact gone up, es­pe­cially in women hav­ing cae­sar­ian sec­tions. They put this down to an in­crease in “de­fi­cien­cies in the qual­ity of ma­ter­nal health ser­vices” – es­pe­cially in emer­gency pa­tient trans­port, avail­abil­ity of in­ten­sive care units, and pro­vi­sion of rapid care for crit­i­cally ill women in preg­nancy and child­birth.


The prob­lem can seem over­whelm­ing, but by pres­sur­ing gov­ern­ment, by tak­ing re­spon­si­bil­ity for our own health, and by spread­ing the word to other women in our cir­cles, we can all help com­bat the main driv­ers of ma­ter­nal mor­tal­ity. The so­lu­tion, it seems, lies in:

1. An­te­na­tal clinic at­ten­dance: Women need to start this as early as pos­si­ble (be­fore five months of preg­nancy) to pick up on con­di­tions such as hy­per­ten­sion (high blood pres­sure), anaemia (low blood lev­els), HIV and com­pli­ca­tions as­so­ci­ated with the abuse of al­co­hol and other sub­stances which af­fect the growth of the foe­tus, and need re­peated and care­ful in­ves­ti­ga­tions in preg­nancy, says Prof Jack Mood­ley, chair­per­son of the Na­tional Com­mit­tee on Con­fi­den­tial En­quiries into Ma­ter­nal Deaths. Women can also get di­etary ad­vice and folic acid sup­ple­ments vi­tal in the first trimester to pre­vent spina bi­fida in their ba­bies, and get ART if they have HIV, to pre­vent trans­mit­ting in­fec­tion to their ba­bies. “Many women in South Africa drink dur­ing preg­nancy and the coun­try has the high­est rates of foetal al­co­hol syn­drome in the world,” says Matthew Cher­sich, As­so­ciate Pro­fes­sor in the Wits RHI.

“They can get coun­sel­ing about drink­ing dur­ing preg­nancy and sup­port to stop harm­ing their child.” Mood­ley adds: “Women must plan their preg­nan­cies and ide­ally visit a doc­tor ex­pe­ri­enced in the care of preg­nant women to rule out chronic con­di­tions like kid­ney dis­ease and di­a­betes, or so these con­di­tions can be con­trolled be­fore preg­nancy.” 2. Ac­cess to con­tra­cep­tion/fam­ily plan­ning: Women need easy, non-judg­men­tal ac­cess from an early age to pre­vent un­planned preg­nan­cies, which they may only dis­cover when al­ready many months preg­nant, Mood­ley says. They not only miss out on the ben­e­fits of early an­te­na­tal care, but may con­tinue con­sum­ing al­co­hol, us­ing drugs, smok­ing and do­ing other things that put them and their grow­ing baby at risk of com­pli­ca­tions. It’s for these rea­sons that in the USA, the dis­pro­por­tion­ately high in­ci­dence of ma­ter­nal deaths among black women has been linked largely to 50% of preg­nan­cies be­ing un­planned, ac­cord­ing to the CDC. “Dur­ing preg­nancy women must be in­formed about fu­ture preg­nan­cies and con­tra­cep­tion, and be of­fered im­me­di­ate post-par­tum con­tra­cep­tion be­fore hos­pi­tal dis­charge or six weeks af­ter preg­nancy,” Mood­ley adds. 3. Ex­tended child-sup­port grants: The re­searchers of the Grow­ing In­equities study rec­om­mended that ex­ist­ing child sup­port grants be­gin dur­ing preg­nancy, so as to “al­le­vi­ate the in­di­rect costs of ac­cess­ing ser­vices, such as trans­port”. They note that grants given dur­ing preg­nancy have in­creased the use of ser­vices in Latin Amer­i­can and Asian coun­tries, and led to “marked im­prove­ments in ma­ter­nal and health out­comes”.

4. Bet­ter ac­cess to HIV test­ing in at-risk groups: Gov­ern­ment needs to fo­cus on women with rel­a­tively low-test­ing but high-HIV preva­lence, the re­searchers ad­vise – like older women or those in tra­di­tional house­holds, who may not re­alise they are at risk.

5. Bet­ter nu­tri­tion: In her study, So­cial Fac­tors De­ter­min­ing Ma­ter­nal and Neona­tal Mor­tal­ity in SA, Rose Mmusi-Phetoe notes that “lack of ad­e­quate nu­tri­tion emerged as a ma­jor theme con­tribut­ing to in­creased mor­bid­ity (ill­ness) and mor­tal­ity… Although starchy food­stuffs were avail­able, pro­tein-rich food­stuffs were re­ported as be­ing scarce and un­af­ford­able.” She quotes a woman in her study telling her: “The health pro­fes­sion­als ad­vise us that we should eat healthy; they don’t have any idea if we have the food that they tell us to eat… Right now I am preg­nant and I can’t feed my­self… I am not work­ing… We eat only in the evening when every­one is home, mostly por­ridge and sour milk or pap and chicken liv­ers or pap and achaar… the food is not good for a preg­nant woman.”

6. Bet­ter over­all health: In the USA, black women have a higher rate of chronic con­di­tions such as obe­sity, di­a­betes and hy­per­ten­sion that make hav­ing a baby more risky, and the sit­u­a­tion is the same here, Mood­ley con­tin­ues. The lead­ing di­rect causes of ma­ter­nal death are haem­or­rhage, high blood pres­sure and em­bolism, and black women are at higher risk of these than white, notes an­other USA study. Black women have nearly three-times the risk of death from haem­or­rhage than white. This has been linked to poor diet, obe­sity and stress, but “more pub­lic health sur­veil­lance and pre­ven­tion re­search is needed”.

7. Bet­ter sup­port by part­ners: Mmusi-Phetoe re­ports “ne­glect and aban­don­ment by male part­ners” to be the sec­ond most im­por­tant so­cial fac­tor in poor health out­comes for women in preg­nancy and child­birth: “Aban­don­ment by a part­ner, es­pe­cially when preg­nant, was nar­rated as a deeply de­grad­ing and hu­mil­i­at­ing ex­pe­ri­ence, caus­ing se­ri­ous ill health.” She quotes a 21-year-old in­ter­vie­wee: “All they want is to sleep with us; when we fall preg­nant, they run away. One be­comes a lugh­ing stock in the com­mu­nity.” Stress has been linked to one of the most com­mon preg­nancy com­pli­ca­tions: preterm birth. In the USA, black women are 49% more likely than white women to de­liver pre­ma­turely (March of Dimes Pre­ma­tu­rity Cam­paign 2016 Re­port Card). The sit­u­a­tion is thought to be sim­i­lar in SA, Mood­ley ex­plains.

Re­silience comes with tak­ing care of your­self – tak­ing time to re­flect and build on your ex­pe­ri­ences, so you can coun­ter­act some of the trauma, be­gin to heal

8. Re­jec­tion of abu­sive part­ners: All the par­tic­i­pants in MmusiPhetoe’s study also re­ported be­ing ei­ther phys­i­cally, emo­tion­ally or fi­nan­cially abused. One 20-year-old in­ter­vie­wee said: “Through­out preg­nancy he beat me, forc­ing me to sleep at his place so that he can have sex with me, when he knew that he didn’t love me. He was just us­ing me.” Mmusi-Phetoe says: “We need to ask why men im­preg­nate women and then disappear. More­over, why is the ap­par­ent ab­sence of re­spon­si­ble fa­ther­hood so eas­ily tol­er­ated by the women? A pos­si­ble ex­pla­na­tion is that in a pa­tri­ar­chal so­ci­ety, women’s sex­u­al­ity is shaped in ser­vice of men’s needs and de­fined ac­cord­ing to male norms.”

9. Bet­ter ed­u­ca­tion: This seems the surest way out of the poverty that un­der­lies so much ma­ter­nal ill-health and death – and out of some of the un­equal re­la­tion­ships that un­der­lie abuse. “In ad­di­tion, schools should be­gin ed­u­ca­tion about sex­u­al­ity and re­pro­duc­tive health mat­ters as early as pos­si­ble,” Mood­ley says.

10. Safe oth­er­hood goals: The Safe

Mother­hood Ini­tia­tives are the USA’s vi­sion for achiev­ing so­cial and pol­icy changes to en­sure safe mother­hood, and would make a dif­fer­ence in SA too, if im­ple­mented. They in­clude:

Women and men are equal part­ners in so­ci­ety

Women and men as­sume re­spon­si­bil­ity for mak­ing mother­hood safe

Women are educated and em­pow­ered to make in­formed de­ci­sions for child­birth choices.

Mother­hood takes place in a phys­i­cal en­vi­ron­ment and so­cial sys­tem that pro­motes well-be­ing for all women

Women re­ceive proper care based on need, and there is no dis­crim­i­na­tion based on abil­ity to pay, place of res­i­dence, cul­ture, re­li­gion or eth­nic back­ground.

The use of tech­nol­ogy and in­ter­ven­tions in child­birth is in­di­vid­u­alised to the health needs of each woman.

(Safe Mother­hood USA’, Jour­nal of Ob­stet­ric,

Gy­nae­co­logic and Neona­tal Nurs­ing.)


To pro­tect your­self and your baby’s health, you need to plan your preg­nancy. “The ideal time is be­tween ages 22 and 26 – this is when the fewest com­pli­ca­tions in preg­nancy oc­cur”, says Prof Mood­ley. “In­crease your space be­tween preg­nan­cies to more than two years, and get ad­vice about fam­ily size. Ap­pro­pri­ate nu­tri­tion and mod­er­ate ex­er­cise for 30 min­utes a day lead to healthy, suc­cess­ful preg­nan­cies.”

You need a bal­anced diet with fruit and veg­eta­bles, whole grains, cal­cium-rich foods and pro­tein, says Dur­ban di­eti­tian Dudu Mthuli. “Kick bad habits and lay down stores, es­pe­cially of folic acid, which the foe­tus will need even be­fore you are aware you are preg­nant. You must also watch your weight!”

Iron de­fi­ciency is com­mon in women of re­pro­duc­tive age be­cause of blood loss from men­stru­a­tion and poor diet, says Cape Town ob­ste­tri­cian/gy­nae­col­o­gist and fer­til­ity spe­cial­ist Dr Sascha Edel­stein. So be­fore con­cep­tion and dur­ing preg­nancy, eat iron-rich foods like lean meat, poul­try and iron-for­ti­fied ce­re­als.

In light of the lis­te­rio­sis scare, re­mem­ber to wash fruit and veg­eta­bles. Avoid un­pas­turised milk and soft cheeses, cook meat and eggs well, and heat pro­cessed meats un­til steam­ing hot to kill any bac­te­ria, says Prof Elna Buys, head of Con­sumer and Food Sci­ences at the Univer­sity of Pre­to­ria. Wash your hands of­ten.

If you strug­gle to quit al­co­hol or drugs, speak to your health pro­fes­sional, or con­tact the SA Na­tional Coun­cil on Al­co­holism and Drug De­pen­dence, 076 535 1701, www. san­ca­na­

To quit smok­ing, re­mind your­self it ex­poses you to about 7 000 chem­i­cals, says Sav­era Kalideen, ex­ec­u­tive di­rec­tor of the Na­tional Coun­cil Against Smok­ing. Women who smoke pro­duce fewer eggs of poorer qual­ity, and their ba­bies are more at risk of cot death, and of leukaemia and brain tu­mours. Her ad­vice is to just ring a cal­en­dar date and quit on that day. Throw out your cig­a­rettes and ash­trays, wash bed­ding and cur­tains to lose the smell. It takes about 10 days for the worst with­drawal symp­toms to ease, Kalideen says. Keep re­mind­ing your­self of the rea­sons to quit (pin up a baby pic­ture or scan), and ask for sup­port: call the NCAS helpline, 011 720 3145, visit www.again­stsmok­

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