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SOUTH AFRICA: Failing Women as Maternal Mortality Quadruples

CAPE TOWN, South Africa, Aug 9 2011 (IPS) - Only six sub-Saharan African countries have failed to reduce the number of women dying in childbirth over the last two decades. High-spending South Africa is among them, with maternal mortality rates more than quadrupling since 1990. Human Rights Watch researcher Agnes Odhiambo says this is largely due to a lack of accountability.

Maternal mortality rates in sub-Saharan Africa as a whole have been reduced by a quarter compared to 1990 levels. But the continent’s most developed economy is moving in the opposite direction: South Africa’s maternal mortality rate in 1990 was 150 per 100,000 live births; in its 2010 MDG progress report, the country reported this had risen to 625 per 100,000.

“HIV is a big factor in maternal mortality in South Africa,” says Odhiambo, adding that improved reporting means deaths that might have gone unrecorded in the past have also been added to the total.

“But even with all that, the kind of negligence that is happening in our facilities… from what women were saying, substandard care is a big problem and that is an issue that we truly have to think about.”

Health workers failing patients

‘A lady and her baby died in our ward’

Abeba M., a refugee from Ethiopia living in Port Elizabeth, told Human Rights Watch about a range of delays, abuses, and negligent care she experienced when she sought help in 2008 for severely high blood pressure when she was 28 weeks pregnant. Her private doctor had referred her to Dora Nginza hospital for blood pressure treatment.

"The nurses swore at me and insulted me… I was admitted at the hospital and told I would stay there until my blood pressure stabilised. But it was going up every day. I was supposed to be taken for a scan to check if the baby was okay. The doctor kept telling me he would take me to have the scan but he did not. He kept saying he had forgotten. So, for 10 days he forgot about me and I was there in the ward where everybody could see me?…

"A lady and her baby died in our ward. I did not think I would survive. Later, another woman suffering from high blood pressure also died. I thought I was next. I was so sick. I had blurred vision. When the second lady died, the nurse asked me, "oh, you are still alive?" and the doctor said, "That lady is dead? Who is next?"…

- from the Human Rights Watch Report ‘Stop Making Excuses: Accountability for Maternal Health Care in South Africa’

Between August 2010 and April 2011, Human Rights Watch interviewed 157 women who made use of maternal care in the public health system in the Eastern Cape Province. Researchers also visited 16 health facilities in districts the national health department has identified as having among the highest maternal mortality ratios in the country, and spoke with frontline health workers and managers, as well as experts in the field.

The survey, ‘Stop Making Excuses: Accountability for Maternal Health Care in South Africa’, reveals a picture of serious neglect, including women in labour being sent home from hospitals without being examined, women ignored or made to wait for hours – even days – by nurses when they asked for help, women being physically and verbally abused by staff, and others forced to change their own sheets or carry their newborns around the hospital while still weak from giving birth. Women with HIV and those from other parts of Africa also reported experiencing discrimination.

“For me, that is failing women,” says Odhiambo. “You fail women when a woman loses her baby and you don’t even bother to explain to her what caused the death of that baby… Or when women are made to clean up their own blood, or when women are forced to sleep (in the same bed) with their baby barely three hours after a c-section, when they’re not yet strong enough.”

The provincial secretary for the National Education, Health and Allied Workers Union (Nehawu) in the Eastern Cape, Xolani Malamlela, acknowledged that health workers’ performance sometimes falls short, but said the union’s assessment is that the problem begins with poor management of health institutions.

Malamlela says that health workers are frequently overworked and are not always paid on time, leading to a demoralisation of staff. He also says procurement policies that have centralised control of stocks of medicine and equipment in the provincial capital have deprived individual hospitals of the capacity to manage vital supplies.

“But we cannot deny that you might here and there find those reckless staff… and we must also play our part in encouraging our members not to deal with patients in a very reckless manner,” he says.

Managers failing patients and health workers

Odhiambo’s report is critical of a failure to act on complaints – not only in sanctioning individual health workers but in recognising system-wide problems that contribute to abuse and neglect. She points out that South Africa’s health authorities are negligent on another level, in failing to collect appropriately detailed information about maternal mortality that would guide policy.

The country has not conducted a Demographic and Health Survey since 2003, for example. Cost is cited as the reason for the delay, but countries with lesser resources have more up-to-date statistics.

“Our health systems are challenged,” says Marion Stevens, a midwife and member of Women in Sexual and Reproductive Rights and Health. She says the main factor in maternal deaths is HIV/AIDS, but argues that the national health department’s focus on the pandemic is poorly executed.

“Accountability is an important issue, because it asks the question why. With all the resources that are being spent on AIDS, why are we not looking also at women’s health, and in particular at maternal mortality as a related issue?”

The focus on AIDS, she says, has come at the cost of considering a continuum of health care. For example, women are told not to go for antenatal care until they are 20 weeks’ pregnant because clinics are overwhelmed by other demands.

“So for women who are ill when they’re pregnant, if they want to get well, or if they are HIV-positive, or if they want to choose to have an abortion, then they essentially come in very very late, and that’s problematic.”

Stevens says the health department has designed a powerful new strategy for sexual and reproductive health rights which provides for greater accountability and integrating issues of HIV and AIDS into a holistic view of women’s health, but since it was completed in May, the document has been sitting on someone’s desk.

Restoring accountability

Odhiambo says that South Africa’s health system lacks adequate monitoring by patients. “A lot of monitoring of what is going on has been done from a provider point of view, but I think there’s a need to bring in patients to say what is not working for them.”

She envisions that this could help to break down the barrier between health workers and users of the system. “Health workers are feeling targeted by this notion of patient complaints, but they’re feeling targeted because the mechanism is not being used in the way it should.

“If patient complaints are implemented properly, then health users and health workers should be friends, because health users are complaining about the problems they’re facing in different facilities, as are health workers and nurses, so the two can really join forces and push the government to make the changes needed so that you’ve got happy users and happy providers.”

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