In South Africa, 310 pregnant women out of every 100 000 die annually as a result of poor care during pregnancy. This is one of the worst maternal mortality rates in the world. But these deaths can be avoided.
Pregnancy and the birth process have always brought joy and pain for a woman. During pregnancy, a woman is almost certain to experience health challenges. The delivery of a baby may also not be flawless.
"It's an exciting time period the growth of a child in-utero the development and knowing what's going on, notwithstanding there are certainly challenges and, sometimes, people experience pregnancy in not such a happy light. Obviously, there are changes that happen to a body that will certainly make people more vulnerable to, maybe infections, to diseases, to risky periods - I mean, delivery is a potential time where all sorts could go wrong, such as bleeding if there's obstruction. So, it needs to be managed. But it doesn't have to be something that is abnormal and it's certainly not an illness", says Dr Vivian Black, Director of Clinical Programmes at Wits University's Reproductive Health and HIV Institute (WRHI).
Black says the first step a woman should take in managing her pregnancy is to seek medical attention as soon as she realises that she is pregnant.
"Pregnant women need to access antenatal care as early as possible. The bottom line is it is never too early in pregnancy to be seen by a health care facility. And if a woman attends a health care facility, and is pregnant, and is turned away because she is attending too early, that is not acceptable intervention. And they need to stand up for their rights and say: 'No, this is not acceptable. I am pregnant and I know my rights. I know that I should be seen at a health care facility as early as possible. If you are not going to see me, I am going to escalate this'," she says.
New protocols for maternal care require women to attend an antenatal clinic at 12 weeks of pregnancy. However, seeking health care earlier is advantageous for many reasons. One of them is to find out about a woman's HIV status and, if positive, to get treatment for herself and prophylaxis to prevent infecting the yet to be born baby. It's estimated that 1 in 3 pregnant women in South Africa has HIV and the infection accounts for the majority of adverse outcomes in pregnant women.
"If we are going to tackle maternal mortality seriously, we have to tackle the HIV epidemic and, particularly, in this case, around women and around the whole pregnancy time when there is transmission of HIV to infants. And that's very complex because that can be anything from tackling gender-based violence, tackling gender relationships, to developing new products that women can use to protect themselves against HIV", says the Executive Director of the WHI, Professor Helen Rees.
Pregnancy is also one of the most opportune times for HIV infection to occur. So, it's important for partners to be open about their HIV status, to consistently and carefully use condoms and not to stray away from each other.
"During pregnancy the cervix or the bottom of the uterus is a lot more friable and more likely to bleed. And we know where blood is involved one finds more virus than just in genital secretions without blood. There may also be behavioural factors possibly linked to partners perceiving that because their primary partner or the pregnant partner may not be as sexually active or desire sex as frequently, might go and look for other partners and bring HIV into relationships as well from third parties", warns Dr Black.
Apart from HIV, there are four factors that contribute to women dying during or shortly after pregnancy. Those are severe bleeding following child-birth, infections, hyper-tensive disorders and unsafe abortions. In a country where many pregnancies are probably unplanned, women and men are advised to use condoms and other contraceptive methods if they want to avoid pregnancy. Black also encourages birth-spacing to avoid the adverse consequences that may result for a woman.
"It's a physiological state, but it's a high demand time they will experience - blood loss, increased nutritional demand. And if you're coming from an environment where you do not replace that adequately, you may find yourself having a subsequent pregnancy when your body is not in an optimal condition. You may be anaemic, you may be nutritionally-depleted, you may have other issues and,certainly, that additional demand on the body will reduce your chances of having an optimal pregnancy and delivery. And, certainly, we know that paediatric health outcomes also are improved with birth spacing and planning that the bigger the delay between children, the more optimal their health outcomes", she says.
Another key factor that adds to the country's bad maternal health outcomes, unfortunately, is beyond the control of a pregnant woman. Many of the maternal deaths are the result of unskilled health workers failing to diagnose and treat problems. This is one of the challenges that the re-engineering of the health system and the introduction of the National Health Insurance will have to address.