Maternal deaths due to non-pregnancy-related infections Third report on Confidential Enquiry into Maternal Deaths in South Africa, 2002-2004

Non-pregnancy-related infections (NPRIs) remain the leading cause of maternal deaths at all levels of care in the triennium 2002-2004, with AIDS deaths being the biggest challenge for the health sector. A total of 1 246 deaths from NPRIs were reported for the triennium. HIV testing of women increased from 37.6% in 1999-2001 to 50% in 2002-2004. Of all deaths from NPRI, AIDS contributed 53.1%, followed by pneumonia (25.4%), tuberculosis (8.3%) and meningitis (6.3%). Malaria deaths declined from 5.3% in 1999-2001 to 1.3% in 2002-2004. AIDS continues in this report to be underestimated because a strict definition of AIDS is used. Many women die before the results of HIV testing are known and it is conceivable that some of them would have been classified as having AIDS. In order to make a diagnosis of AIDS, a positive HIV test plus an AIDS-defining condition must be present. There are provinces that need to improve access to voluntary counselling and testing. AIDS remains the main cause of death in all age groups, followed by pneumonia, tuberculosis and meningitis, with the age category 25-29 years being at most risk for all four. The commonest final and contributory causes of death were respiratory failure or immune system failure, which occurred in more than 50% of patients. Deaths occurring at level 1 hospitals increased sharply. Deaths in level 2 hospitals were second highest. Patients presented with an emergency equally in the antenatal period (44.2%) and in the postpartum period (43.7%). Patient-related factors decreased from 68.8% in 1999-2001 to 46.2% in 2002-2004. These were reported as the commonest avoidable factors. Delay in seeking help was the main contributor, followed by lack of antenatal care. Lack of health care facilities, personnel and transport are the main administrative avoidable factors and may contribute to people feeling that they are not welcome in the health care system. The use of the CD4 cell count is not yet universal. There are personnel-related factors, such as fatalism and a non-caring attitude once a diagnosis of HIV infection is suspected or made. Delay in providing care is a factor in the management of many women with HIV and other infective conditions. There is also lack of utilisation of the ethical guidelines for management of women with HIV infection.