Cape Town — In a country where deaths from pregnancy and childbirth have been rising - more than four-fold in a decade, according to reports - not a single maternal death was recorded at a midwife obstetric unit in Khayelitsha, a poor settlement outside Cape Town, from April 2011 to May this year.
The achievement speaks eloquently of what can be accomplished by providing a full spectrum of services while caring for HIV-positive mothers and preventing the transmission of the virus to their newborn babies.
It also serves as a startling contrast to the mounting rate of deaths among mothers in sub-Saharan Africa's wealthiest economy, one moreover in which the government spends more per person on health than any other in the region.
South Africans have a constitutional right to health care, to access contraception and to have their pregnancies terminated. Maternity care is free and nearly nine in 10 women give birth in a health facility. But the country also has one of the world's largest HIV/Aids burdens. An estimated 5.7 million citizens are living with HIV and 30.2 percent of pregnant women are HIV positive.
The South African government's health records, numerous independent research papers and a report released last year by Human Rights Watch all point to a link between HIV and the rise of deaths during pregnancy and childbirth.
The South African Department of Health notes in its fifth "Saving Mothers Report" that from 2008 to 2010, the "big five" underlying causes of deaths among mothers were non-pregnancy related infections. They accounted for 86.5 percent of maternal deaths.
HIV infections - complicated by accompanying infections such as tuberculosis (TB), pneumonia and meningitis - were responsible for 40 percent of maternal deaths. Hypertension and obstetric hemorrhage were the next most common cause, followed by pregnancy-related sepsis and medical and surgical disorders.
More than a decade ago, operating out of offices in Khayelitsha, the medical humanitarian organization, Médecins Sans Frontières (MSF), was a pioneer in bringing antiretroviral therapy to a resource-limited setting.
MSF is still there, and Dr. Vivian Cox is its deputy medical field co-ordinator. Seated in a small office above a noisy shopping centre, she explains that HIV's suppression of the immune system exposes pregnant women to a variety of deadly diseases. The most common opportunistic infection, she says, is TB.
"TB and HIV co-infection in pregnancy is particularly devastating for a pregnant woman," she adds, "both in terms of treatment options and the danger of transmission to the child in pregnancy or during birth."
A further risk is anaemia, caused by low hemoglobin (low numbers of red blood cells), which often occurs in pregnant women. "If you compound the anaemia of pregnancy with a potential anaemia of HIV, you are really putting the HIV-infected pregnant woman at a disadvantage at the time of labour and delivery," says Cox. "If she is anaemic and has any sort of post-partum haemorrhage, which is a common complication in pregnant women, then she has much less ability to tolerate that acute blood loss."
A 2011 Human Rights Watch report, "Stop Making Excuses - Accountability for Maternal Health Care in South Africa", claims that the country's maternal mortality rate quadrupled in the decade after 1998, increasing from 150 deaths per 100,000 live births in 1998 to 625 per 100,000 in 2007.
The statistics in the "Saving Mothers" report released in May this year show a continuing increase in maternal deaths over the past six years.
According to the health department, the institutional maternal mortality rate rose from 151.7 per 100,000 live births between 2005 to 2007, to 176.2 per 100,000 live births in the period between 2008 and 2010.
In contrast to this bleak picture, there are corners of the country where giving birth is less risky for both mothers and babies.
The Prevention of Mother to Child Transmission (PMTCT) programme used at the Khayelitsha clinic was designed by the World Health Organisation in the late 1990s and endorsed by the United Nations system. It consists of four components:
1. Prevention of HIV infection among young people and pregnant women
2. Prevention of unintended pregnancies among HIV-positive women
3. Prevention of HIV transmission from HIV-positive women to their infants
4. Provision of treatment, care and support to HIV-infected women and their families.
However, in practice, these programmes have focused solely on the third component - and have largely ignored the need to offer HIV-positive women the means to prevent unintended pregnancies or to provide follow-up care to women and their families.
Contraception as well as termination of pregnancy services are available at clinics in the Khayelitsha area, says Vivian Cox. But the biggest challenge is to encourage women to visit a health facility in the first three months of their pregnancies. This seldom happens.
The most common scenario is that a woman first visits a clinic when she is five months pregnant.
"This reduces the time to test for HIV, to adjust her medication and to reduce transmission to the baby," says Cox. "It is also too late for a medical or surgical termination of the pregnancy if that is what a woman wants."
For Cox, helping to reduce deaths among mothers starts with family planning and enabling them to prevent pregnancies, together with counselling on how to become pregnant safely when a partner is HIV infected.
In addition, reducing deaths also involves providing simple, effective antiretroviral therapy and integrating the HIV clinic with the antenatal clinic.
"HIV treatment can't exist separately from treating chronic diseases or providing basic antenatal care in pregnancy," Cox says.
"As many as five or six years ago, MSF was already saying that the provision of HIV care needs to occur in the antenatal clinics and in the midwife obstetric units. Bringing the treatment and the medications closer to the patients greatly increases the number of patients you'll reach and the number of patients who'll stay on treatment."