By: Sarah Osman, MSc.
Contributors: Mantshi Teffo-Menziwa and Denise Hunt, Marie Stopes South Africa
In South Africa, a paradox ensues when looking at data on women’s reproductive health. The last Demographic and Health Survey (DHS) of 2003 states that 90 percent of pregnant women received antenatal care and 91 percent of births were attended by a skilled health practitioner, yet the latest estimates of maternal mortality in the country approximate the maternal mortality ratio (MMR) at up to 625 per 100 000 live births. The same DHS reports that 65 percent of women in South Africa are using a modern form of contraception, yet recent cross-sectional studies show that over 60 percent of most recent pregnancies are unplanned.
These contradictions show that we are very far from making pregnancies desired and safe. Indeed, in its 2010 Millennium Development Goal (MDG) report, the South African government states that it is unlikely for the country to reach MDG 5 by 2015.
Since the publication of the 2010 MDG report, there has been renewed commitment from the South African Department of Health (DoH) to seriously address sexual and reproductive health and rights (SRHR) in order to not only meet MDG 5, but also MDGs 3, 4 and 6. This commitment is summarised in a new 10-year policy entitled Sexual and Reproductive Health and Rights: Fulfilling our Commitments 2011–2021 and beyond. The core of the policy is that a fragmented approach to the different components that comprise SRHR will not lead to improved SRH, and will most certainly not lead to improvement in women’s health.
However, an implementation plan is needed to match this commitment to make serious progress towards MDG 5.
This paper looks at the current factors, other than hypertension and obstetric haemorrhage, that most highly correlate with MMR in South Africa (HIV infection, unplanned pregnancy and unsafe abortion) and lists some interventions that can significantly decrease the MMR in South Africa by 2015.
HIV infection and maternal mortality
With the feminisation of the HIV epidemic and the fact that over 44 percent of maternal deaths are attributed to complications related to AIDS, the role that the HIV epidemic plays in maternal mortality could not be ignored.
The number of maternal deaths due to AIDS classified as clearly avoidable rose from five percent in 2004 to 18 percent in 2007. This is despite a health system that has a strong HIV counselling and testing policy and strong standards and guidelines on antiretroviral therapy.
So, what led to this increase in AIDS related deaths? One of the main reasons is the fact that HIV continues to be separated from a broader SRHR framework.
A focus on the prevention of HIV alone has overshadowed efforts to control the spread of sexually transmitted infections (STIs), even though they correlate directly with HIV transmissions. The WHO states that the prevalence of STIs “could account for 40 percent or more of HIV transmissions”. Research shows that STI prevalence in South Africa is relatively high and that most STIs are unrecognised and incorrectly treated. For example, some studies reported the prevalence of trichomoniasis as high as 24 percent among women in KwaZulu-Natal.
This high prevalence is linked to the quality of treatment of STIs in South Africa, which was found to be poor with only 10 to 40 percent of patients being given correct medication. In general, clients are treated symptomatically for STIs, which was shown to be ineffective in reducing the incidence of STIs as clients may be infected, but not showing any symptoms of the STI. A study measuring the effect of STI treatment on HIV infections in four African cities showed that “...in African populations with mature HIV epidemics, STI treatment interventions are likely to remain highly cost-effective and may even be cost-saving, particularly in populations in which safer sexual behaviours have not adequately controlled STIs and HIV incidence remains high”. Furthermore, in a comparative study, the Human Sciences Research Council (HSRC) found that the control of STIs is one of the top three most effective methods in preventing HIV transmission.
A majority (estimated between 55 percent and 93 percent) of new HIV transmissions occur in stable and long-term relationships. Studies show that despite positive outcomes such as managing transmission risk with behavioural and biomedical interventions, couple-oriented programmes are not implemented on a large scale. In order to stimulate and strengthen HIV prevention efforts, increased attention is required to promote prevention, testing and counselling for couples in stable relationships. Through couple-oriented voluntary counselling and testing and integrated SRH services, seroconcordant or serodiscordant couples will be in a better position to make healthy reproductive choices, for example, to prevent pregnancy, or to ensure a healthy pregnancy or healthy child delivery.
Unplanned pregnancies and maternal mortality
Multi-country data shows that planned pregnancies can help to avert up to 32 percent of maternal deaths. Although the contraceptive prevalence rate in South Africa is amongst the highest in sub-Saharan Africa (65 percent), the consensus amongst practitioners and social scientists in the country is that the provision of quality fertility management services is failing. This is a result of the lack of integration of SRH services and HIV services over the last decades, as recently pointed out by the head of UNFPA.
Overall, the use of long-acting methods of contraception in South Africa is severely limited with national prevalence of the intra-uterine device (IUD) at 0.8 percent. This lack of uptake can be attributed to issues of both supply and demand. Sterilisation is more widely recognised by women than the IUD, signalling a critical knowledge gap and highlighting an immediate need for education and behaviour change interventions within South African communities. Exacerbating a lack of demand for long-term methods is the severely limited supply of services. The use of the IUD, for example, is hindered by the fact that knowledge of the method among nurses in the public sector is inaccurate with a self-reported need for training in IUD insertion and removal. The private sector in South Africa is currently playing a critical role in providing choice in contraceptive methods, with 50 percent of all those taking up IUDs doing so through the private sector, however capacity is severely limited and the absence of skills development and training has resulted in variable service quality. The implant, which has been shown to be safe and cost-effective, has only been registered in South Africa this year, while it has been available in other African countries for several years. Combined, these issues highlight the fact that a full range of contraceptive methods is neither promoted nor available in South African communities.
Civil society organisations in South Africa share the DoH’s concern over the decline in the efficacy of fertility management programs resulting in poor sexual and reproductive health outcomes, which continue to hinder the country’s development and have called for intervention. This is backed up by national surveys indicating that fertility management services in South Africa have not improved over the past eight years and bringing into question national strategies for the provision of contraceptives which has led to the under resourcing of public facilities and a reliance on a largely under-equipped private sector. It is imperative to deliver long-acting methods of contraception by increasing choice and uptake of appropriate methods of contraception among target populations. This will ultimately reduce the number of unplanned pregnancies and associated morbidity and mortality, contributing to a reduction in South Africa’s MMR.
Unsafe abortion and maternal mortality
Since the legalisation of abortion in South Africa in 1996, the number of abortion-related mortalities has decreased dramatically. Unfortunately, needless unsafe abortion related mortalities have not been eradicated. According to the DoH, 4,077 maternal deaths were reported between 2005 and 2007. The DoH further reports that 38.4 percent of maternal deaths were avoidable. Of these avoidable deaths, 45.9 percent are attributed to delay in seeking medical help (26.7 percent), unsafe abortion (25.7 percent), no access to antenatal care (17.7 percent) and infrequent antenatal care (six percent) . Unsafe abortion remains one of the top five avoidable and patient-related causes of maternal deaths in South Africa. Mortalities associated with unsafe or incomplete abortions have risen by 4.6 percent between 2004 and 2007. Improving the quality and coverage of reproductive health services, namely contraceptive and safe abortion services, was one of the four main recommendations put forward in reducing the number of maternal deaths.
There has been no decline in unsafe abortion related morbidity and the number of women who are critically ill because of incomplete abortions, indicating that unsafe abortions are still rampant. For instance, a study published by the South African Medical Research Council in 2010 reports that 48.5 percent of abortions undergone by young people between the ages of 13 and 19 took place outside a hospital or clinic and were therefore likely to be unsafe.
Women in South Africa continue to seek abortions outside hospitals and clinics for various reasons. A qualitative study by the World Health Organisation (WHO) on abortion services in the Western Cape showed that “providers’ reluctance to be involved in different aspects of abortion provision led to complex and fragmented levels of service provision throughout many of the healthcare facilities". Anecdotal evidence from Marie Stopes South Africa clients supports these claims, suggesting that although public health facilities are legally required to provide abortion on request, most public-sector nurses frequently refuse to provide the service due to conscientious objection. Younger clients, who are reportedly the majority that access abortion services outside the health facilities, are often chastised for being sexually active, for being ‘irresponsible’, and for choosing to terminate the pregnancy rather than give birth. Clients also report being repeatedly turned away from public hospitals because the facility has reached its weekly abortion quotas or does not provide the service at all.
The decentralisation of authority in the DoH, though a positive step, has lead to huge disparities in access to safe abortion across South Africa’s nine provinces. Indeed, experts in civil society often refer to the ‘Nine Health Systems’ in the country, pointing to the large discrepancy in health outcomes from province to province. The re-engineering of primary healthcare is viewed as an effective strategy in reducing the inequalities and inequities of the current, mainly curative, health system.
According to an evaluation conducted in 2008, of 292 public facilities designated to provide safe abortions in the country, only 151 (52 percent) were functional. Certain provincial health departments lay out extremely restrictive minimum requirements for abortion-providing facilities, for example, that abortion facilities are required to meet private hospital regulations such as full operating theatres, two-meter wide passages, piped gas available at each bed, etc. These requirements restrict small medical facilities that could safely provide abortions from doing so. Furthermore, the DoH approved mifepristone-misoprostol medical abortion in 2001 for abortions up to 56 days. Although some provinces have developed and implemented medical abortion guidelines, a guideline for the use of this method in the public sector has not yet been finalised nationally.
Knowledge among women of their right to an abortion upon request is another major hindrance to women seeking safe abortions: at least one-third of sexually active women believe the service remains illegal. A reason for this misinformation is the fact that in 2004, an amendment to the 1996 Choice on Termination of Pregnancy (CTOP) Act was passed to allow registered nurses with appropriate training to perform first-trimester abortions. A challenge to this amendment was put forward in 2006. An 18-month delay in court ruling that was misreported by the media, led to confusion among the public as well as among service providers, leading women and service providers to incorrectly believe that abortion was no longer legal in South Africa. This has had major consequences in upholding women’s rights to abortion services in the public sector and the situation has not been sufficiently rectified. In 2010, knowledge of the CTOP Act was found to be just as weak among service providers including health managers. Women are therefore unlikely to seek safe abortions through official or regulated channels and will instead opt for an unsafe service. Additional reasons cited for not using legal services include knowing the law but not knowing where to access safe abortion; anticipation of rudeness from judgmental staff (particularly in public facilities); and concerns over the confidentiality of the service.
Interventions to reduce MMR
Alongside hypertension and obstetric haemorrhage, the MMR in South Africa is further fuelled by HIV infection, unplanned pregnancy and unsafe abortion. In order to reduce the MMR, these factors must be addressed in a systematic manner. To this end, the following are entry-points for the public and non-profit sectors to reduce the MMR:
- Revive focus on the underlying factors behind new HIV infections among women such as STIs, and promote STI testing and treatment;
- Promote long-acting methods of contraception such as the IUD within the public sector;
- Promote the use of emergency contraception for women who take-up short-term methods such as the pill or the injectable;
- Increase the choice in contraceptive methods available to women in the public sector, especially methods such as the implant;
- Strengthen provider skills in the provision of integrated SRH and HIV services in the public and private sector;
- Increase knowledge of the CTOP Act among service providers;
- Publicise public sector facilities that provide abortion;
- Make medical abortion available nationally in public healthcare facilities;
- Increase collaboration between non-profit organisations and the DoH to provide integrated SRH packages through referrals as opposed to vertical, HIV-focused interventions; and
- Address gender-based violence as a contributory direct or indirect factor to MMR.
To learn more about Marie Stopes South Africa, visit www.mariestopes.org.za.
For example, in its HIV and AIDS and STI National Strategic Plan for South Africa, the Department of Health states that it only intends to spend 1% of its prevention budget on managing STIs: http://www.doh.gov.za/docs/misc/stratplan-f.html
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