The fact that most sub-Saharan Africa countries including South Africa (SA) are not on track to meet the 2015 target of improving maternal, neonate and child health (MNCH) is a major public health concern. Since 1990 the situation in SA aroused a lot of research interest in tracing the historical context of the problem, evaluating progress made and actions for improving MNCH.
Globally, high-level support for actions to improve maternal, newborn and child health (MNCH) has gained momentum with the pledge of US$ 40 billion to address women’s and children’s health through the attainment of the United Nations (UN) Millennium Development Goals (MDG) over the five years 2010-2015. MDGs for maternal health (MDG-5) and child health (MDG-4) call for a reduction in maternal mortality by three-quarters and child mortality by two thirds by the year 2015. In SSA where maternal mortality is highest, the annual decline has been 1.7%.
Children continue to die of causes that can be both prevented and treated using proven, low-cost interventions. Progress has been slower for reducing newborn deaths than for deaths among post-neonatal age children. It is estimated that between 66% and 85% of Africa’s maternal, newborn, and child mortality could be prevented through implementation of available interventions.
In South Africa, it is generally accepted that the maternal, neonatal and child (MNC) deaths are unacceptably high, however, the estimates vary depending on the source. In 2009 the National Department of Health gave a maternal mortality ratio estimate of 310 deaths per 100 000 live births, neonatal mortality rate of 14 deaths per 1000 live births and child (under 5 years) mortality rate (CMR) of 56 deaths per 100 000 live births.
Overall the main causes of maternal and child mortality in South Africa are HIV and AIDS, pregnancy and childbirth complications, neonatal illness, childhood illness, and malnutrition, which are all related to poverty and great inequity. These are the countries’ big five challenges that need to be addressed in order to accomplish the health related MDGs.
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The infant and under-five mortality rates are key indicators of heath and development. Ideally this information is obtained from vital registration systems. However, as in many middle- and lower-income countries, the under-reporting of births and deaths renders the South African system inadequate for monitoring directly. South Africa is therefore reliant on alternative methods, such as survey and census data, and modelling (particularly given the lateness in release of registration data), to determine the extent of the deficiency in the registered deaths. These data have been corrected for known biases. In other words, the trends shown in Figure xx are based on nationally representative numbers.
Trends in Infant Mortality Rate (IMR)
Trends since 2000 show that the IMR peaked in 2003 at 54 per 1,000 and decreased to 24 per 1,000 in 2017, after which the IMR rose again slightly before a sudden drop to 20 in 2020. Preliminary estimates by the MRC suggest that infant mortality rates rose sharply in 2021 and 2022, with a corresponding increase in under-five mortality. The revised estimate for IMR in 2022 is 29 deaths per 1,000 live births. Despite slight recovery (to 26 in 2023) the estimated probability of dying in the first year of life remains above pre-COVID levels.
The reasons for rising child mortality after lockdown are unclear as there have been long delays in the release of Causes of Death data by Stats SA. Mortality estimates beyond 2019 are extrapolations from the National Population Register (NPR), which is more prone to error because not all deaths are reported, and even if they are, they are not captured in the NPR if the birth was not registered prior to death. The NPR also does not record births and deaths for individuals who are not South African. In addition, there is quite a bit of uncertainty around the population estimates for children, and for infants in particular. This is partly due to problems with the high undercount of the 2022 census and subsequent adjustments to correct for that.
Given the lack of recent data on causes of death, it is not possible to determine what is driving the estimated increase in mortality between 2020 and 2023.
Neonatal Mortality Rate (NMR)
The neonatal mortality rate (NMR) is the probability of dying within the first 28 days of life per 1,000 live births. The NMR has remained stable, at around 12 deaths per 1,000 live births. Estimates of the NMR are taken from the UN-IGME model, which is in turn derived from neonatal deaths and live births recorded in the DHIS. The NMR estimates therefore exclude deaths that occur at home or in the many private sector health facilities that are not included in the DHIS. The DHIS also records the in-facility neonatal death rate - i.e. the number of infants aged 0 - 28 days who died during their stay in the facility, per 1,000 live births in public health facilities.
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Under-Five Mortality Rate (U5MR)
The under-five mortality rate (U5MR) is the number of deaths of infants and children under five years old per 1000 live births. The under-five mortality rate for the world is 39 deaths according to the World Bank and the World Health Organization (WHO). The infant mortality rate is the number of deaths of infants under one year old per 1,000 live births. This rate is often used as an indicator of the level of health in a country. Note that due to differences in reporting, these numbers may not be comparable across countries. The WHO recommendation is that all children who show signs of life should be recorded as live births.
Challenges and Opportunities
Approximately 25-44% of these deaths had modifiable factors related to family/community action (inadequate ANC, delayed action in seeking help during labour, caregiver and family members not recognizing the severity of the illness). Multifactorial systems related challenges identified included poor health status and care of women, illiteracy plus lack of information with regard to available health services, poor antenatal and obstetric care both within the community and health facilities, absence of well-trained cadre of health extension workers, inadequate referral system and absence of or poor linkages of health centers with the communities.
Furthermore, there are substantial inequalities in maternal and child health service coverage and health outcomes with differences between socio-economic groups and geographical areas within the country. Mothers, babies, and children in poor families are at increased risk of illness and face many challenges in accessing timely, high-quality care. This can also be attributed to poor use of health care facilities by patients, lack of transport and sub-optimal quality of care by some health providers.
In addition, great disparities exist between South Africa’s public and private health care systems with about 40% of the total health care expenditure allocated to the public health care system that caters for about 86% of the population. The distribution and access to essential services is also unequal with the most deprived provinces and districts receiving the least primary care expenditure. Therefore addressing inequities is a pre-requisite to achieving MDGs in South Africa.
Government Initiatives and Progress
Given the magnitude of the problem, a multidisciplinary anonymous investigation sanctioned by the ministerial committee on health was carried out by (i) the National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD), (ii) the National Perinatal Morbidity and Mortality Committee (NaPeMMCo) and (iii) the Committee on Morbidity and Mortality in Children under 5 Years (CoMMiC) at local, regional and national levels. For maternal deaths NCCEMD initially identified four focal points that need to be prioritized and these included improving knowledge development, quality of care and coverage of reproductive health services, establishing norms and standards, and facilitating community involvement.
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For neonates NPMMC recommended clinical skills improvement especially strengthening skills of interns, midwives and nurses; improving staffing, equipment and facilities; proper implementation of national maternal and neonatal guidelines; training and education of health care workers/communities; improving transport and referral routes; improving postnatal care; appointment of regional clinicians to establish, run, monitor and evaluate all outreach programs (at regional, district, hospital and clinic level) for maternal and neonatal health including data collection and review.
For children under 5 years CoMMiC recommended the strengthening of the existing child survival programs adopted by the NDOH which included the Community Health Worker (CHW) program, Integrated Nutrition Program and 10 steps for the management of severe malnutrition, Expanded Program on Immunization (EPI), Integrated Management of Childhood Illnesses (IMCI) and Prevention of Mother to Child Transmission (PMTCT) of HIV during ANC. Additionally, strengthening of essential data systems, identifying key drivers to give and sustain actions required to improve the health of children across the country and developing a national child health strategy.
The revitalization and building of more Primary Health Care (PHC) facilities has significantly increased access to MNCH services at PHC level with over 120 million visits reported countrywide in 2010. Significant shifts in policies towards HIV and AIDS treatment to prevent mother to child transmission is also having a significant impact on HIV related maternal and child mortality. In 2011 a 13% reduction in maternal mortality ratio was reported mainly as a result of decline in deaths from non-pregnancy-related infections such as HIV-infected pregnant women complicated by TB and pneumonia.
The new 2012-2016 National Strategic Plan for Maternal, Newborn, Child and Women’s Health (MNCWH) and Nutrition, has in addition to provision of comprehensive interventions, been linked and aligned with efforts to strengthen the health system particularly through the re-engineering of the Primary Health Care services (PHCs) and district health systems. The main goal of South Africa’s new strategic healthcare and nutrition plan for women and children is to reduce by 10% by 2016: the maternal mortality ratio (MMR); the neonatal mortality rate (NMR); the infant mortality rate (IMR); and the child mortality rate.
Improving maternal, newborn and child survival across the continent depends on each country’s ability to reach women, newborns and children with effective interventions; the provision and use of timely data on quality of care; monitoring and evaluation of health outcomes. Pivotal to the successful implementation of intervention packages for maternal, neonatal and child mortality is the establishment and maintenance of stakeholder partnership strategies to ensure sustainability in the continuum of care.
The South African experience and current MNCH situation may be unique and /or different compared to other countries in Africa given the historical context. However, the political commitment and government stewardship in response to worsening MNCH outcomes is exemplary in the continent. Finally, the use of critical and yet complimentary research for evidence based priority setting in SA, highlights the need for science to inform policy and practice which is often missing in many settings in Africa.
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