Elsevier

The Lancet

Volume 371, Issue 9620, 12–18 April 2008, Pages 1294-1304
The Lancet

Public Health
Every death counts: use of mortality audit data for decision making to save the lives of mothers, babies, and children in South Africa

https://doi.org/10.1016/S0140-6736(08)60564-4Get rights and content

Summary

South Africa is one of the few developing countries with a national confidential inquiry into maternal deaths. 164 health facilities obtain audit data for stillbirths and neonatal deaths, and a new audit network does so for child deaths. Three separate reports have been published, providing valuable information about avoidable causes of death for mothers, babies, and children. These reports make health-system recommendations, many of which overlap and are intertwined with the scarcity of progress in addressing HIV/AIDS. The leaders of these three reports have united to prioritise actions to save the lives of South Africa's mothers, babies, and children. The country is off-track for the health-related Millennium Development Goals. Mortality in children younger than 5 years has increased, whereas maternal and neonatal mortality remain constant. This situation indicates the challenge of strengthening the health system because of high inequity and HIV/AIDS. Coverage of services is fairly high, but addressing the gaps in quality and equity is essential to increasing the number of lives saved. Consistent leadership and accountability to address crosscutting health system and equity issues, and to prevent mother-to-child transmission of HIV, would save tens of thousands of lives every year. Audit is powerful, but only if the data lead to action.

Introduction

Cape Town, South Africa, is the location for the 2008 Countdown meeting, which aims to track progress towards achievement of the Millennium Development Goals (MDGs) for maternal and child survival.1 This meeting provides South Africa with the opportunity to take stock of national progress towards these important goals, which the government has committed to achieving.

In this report, the leaders of three South African national audit reports (Saving Mothers,2 Saving Babies,3 and Saving Children4) unite to review national progress towards the MDGs for maternal, neonatal, and child survival; the direct causes of the deaths; the avoidable causes of death that are emphasised by the audit process; and present coverage and quality of care, which is the focus of the Countdown meeting.1 These audits show the power of counting every death to improve care, at least at the provider-patient interface, although broad change needs system-wide accountability.

Section snippets

Mortality audit for mothers, babies, and children

The recent Lancet Who Counts? series drew attention to the absence of reliable data for births, deaths, and causes of death, and the need to count and account for these deaths to accelerate and track progress for the MDGs.5 In Africa, only two countries—the two island states of Mauritius and Seychelles—have complete information about cause of death through vital registration systems.5 South Africa has fairly high registration compared with many other African countries. Registration coverage for

Progress towards child survival and maternal health

Audit is a useful method, but the final goal is mortality reduction. Are maternal, newborn, and child deaths nationally being reduced or not in South Africa? Although debate surrounds national mortality figures and estimates, all indications are that maternal and child mortality has increased since the baseline for the MDGs in 1990 (figure 1).23 Data for maternal mortality since 1998 are available through the national confidential inquiry,2 and the reported maternal mortality ratio has risen

Causes of death in mothers, babies, and children

Data for maternal death gathered by the NCCEMD have shown that the largest cause of maternal death is non-pregnancy related infections, mainly HIV/AIDS, tuberculosis, and pneumonia, accounting for at least 38% of all maternal deaths (figure 2).2 However, this finding is probably an underestimate since only 46% of the women who died were tested for HIV, and 78% of those who were tested were HIV-positive. Hypertension and haemorrhage (antepartum and postpartum) are major causes of maternal death

Coverage and quality of care

At all levels of the health system, South Africa has health-service packages throughout the lifecycle for mothers, babies, and children, which together form the basis of an effective continuum of care.40 Figure 3 shows national coverage for key interventions for the health of mothers, babies, and children. Little information exists in the postnatal period and for the characteristic cascade of HIV interventions through the years. Despite fairly high coverage of most of the major packages,

Accountability for action

Audit is only effective if there is accountability for action so that recommendations are implanted and assessed—ie, closing the audit loop to result in a cycle of upward quality improvement. Individuals can make a big difference, in some cases even quickly catalysing local changes in processes (panel 2). However, a scarcity of human resources, health-facility infrastructure, and supply systems can be so fundamental that although local process can be improved, the effect at the population level

Conclusions

Much has been achieved during the first 14 years of democracy in South Africa, but many paradoxes remain. At least 260 women, babies, and children die every day in South Africa, and no measurable progress has been made to reduce this mortality rate. This toll is too high in view of South Africa's status as a middle-income country and capacity to provide services. HIV/AIDS, complications from pregnancy and childbirth, newborn illness, childhood illness, and malnutrition are the priority

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