Trends in maternal deaths in HIV‐infected women, on a background of changing HIV management guidelines in South Africa: 1997 to 2015

Abstract

IntroductionAs work begins towards the Sustainable Development Goal target of reducing the global maternal mortality ratio (MMR) to less than 70 deaths per 100,000 live births by 2030, much needs to be done in ending preventable maternal deaths. After 1990, South Africa experienced a reversal of gains in decreasing maternal mortality, with an increase in HIV‐related maternal deaths. In this study, we assessed trends in maternal mortality in HIV‐infected women, on a background of an evolving HIV care programme.MethodsThis was a cross‐sectional, retrospective record review of maternal deaths in the obstetrics unit at Chris Hani Baragwanath Academic Hospital, in Johannesburg, South Africa, a referral hospital in a high HIV prevalence setting where the prevalence among pregnant women has plateaued around 29.0% for the past decade. Trends in HIV diagnosis and management in pregnancy, and causes of maternal deaths in HIV‐infected women were analysed over different time periods (1997 to 2003, 2004 to 2009, 2010 to 2012, and 2013 to 2015) reflecting major guideline changes.ResultsFrom January 1997 to December 2015, there were 692 maternal deaths in the obstetrics unit. Of the 490 (70.8%) maternal deaths with a documented HIV status, 335 (68.4%) were HIV‐infected. A Chi‐squared test for trends showed that the institutional MMR (iMMR) in women known to be HIV‐infected peaked in the period 2004 to 2009 at 380 (95% CI 319 to 446) per 100,000 live births, with a decline to 267 (95% CI 198 to 353) in 2013 to 2015, p = 0.049. This decrease coincided with changes in the South African HIV management guidelines, mainly increased availability of antiretroviral therapy (ART). Non‐pregnancy related infections were the leading cause of death throughout the review period, accounting for 61.5% (206/335) of deaths. Only 23.3% (78/335) of the women who died were on ART at the time of death, this in the context of advanced immune suppression and an overall median CD4 count of 136 cells/μl (interquartile ranges (IQR) 45 to 301).ConclusionIn this 19‐year review of maternal deaths in Johannesburg, South Africa, there was evidence of a decrease in the iMMR among HIV‐infected women, but it remains unacceptably high. Efforts to address drivers of mortality and barriers to accessing ART need to be accelerated if we are to see substantial decreases in maternal mortality.

How large should a cause of death be in order to be included in mortality trend analysis? Deriving a cut-off point from retrospective trend analyses in 21 European countries

“…COD data are used in widely varying settings, ranging from detailed mortality profiles to macro estimates. Applications include studies in localised areas,29 single countries30 or worldwide2 31; for a single-disease32 33 or disease group9; monitored for days or a long-term period7; for specific age groups33 34 or specific situations (eg, maternal mortality,5 external causes35–37). These settings all impose different requirements on the collected data.…”

“…One main factor is the COD size, defined as the mean annual number of deaths, which expresses the rarity of a disease or condition that is selected as underlying COD in a population. Incidence changes or effects of interventions are common factors discussed in mortality trends analyses 4 5. In addition, this probability might depend on other factors, such as the type of COD, or the country of interest.…”

“…For example, neoplasms have been shown to be more gradual in their annual changes,6 whereas infectious diseases7 may have high year-to-year variation. As regards to different populations, the likelihood to detect a long-term trend for a COD may vary between countries because of differences in population size, COD coding practices that may also influence observed mortality trends,8 trends in prevalence of risk factors,9–12 implementation of new prevention strategies,13 14 treatment protocols5 or healthcare reforms 15…”

Hiv Infection and Maternal Mortality

“…(2014) и другие авторы. Согласно обширному исследованию, выполненному в академической больнице Йоханненсбурга в 2013-2015 гг., в структуре материнской смертности ВИЧ-инфицированных женщин гипертензивные расстройства (преэклампсия) составили 18,4%, от кровотечения и проблем в оказании медицинской помощи погибли соответственно 8,2-8,2% беременных и рожениц [3].…”

Maternal Mortality in the District of Uzumba in Zimbabwe

“…Apart from the medical related causes of maternal mortality, Mnyani et al, (2017) and Engin-U et al, (2019) argue that, there are physical aspects such as distance to health facilities, road network and quality, seasonal accessibility, availability of transport that can lead to high maternal mortality. In this context, Uzumba district is a rural area in Zimbabwe where it terms of development it is lagging behind due to negligence of the responsible authorities.…”