UN Integrated Regional Information Networks - August 26, 2009

Although HIV/AIDS has played a major role in the high rates of maternal and child mortality, between a quarter and a half of maternal and child deaths are the result of health-system failures, according to a report in "Health in South Africa", a new six-part series published in the UK-based medical journal, The Lancet.

Despite steadily rising investment in maternal and child health since 1994, health outcomes have failed to improve. The authors identify bottlenecks at regional and tertiary hospitals as part of the problem, suggesting that with more training and support, a higher proportion of care could be provided by district hospitals.

Over-stretched and demotivated health workers are expected to deliver an increasing number of services with little supervision or monitoring. "Reports and observations of rude and sometimes abusive behaviour by health workers, especially in the maternal setting, are widespread," the authors noted.

A recent report on maternal mortality in South Africa said 38 percent of the maternal deaths at health facilities between 2005 and 2007 were avoidable, and included a failure to properly diagnose or manage post-delivery bleeding, hypertension and sepsis.

Prioritise HIV interventions

The Lancet authors said a strategy that "re-energizes and motivates" health workers was a priority, but scaling up HIV interventions for women and children had the potential to save the greatest number of lives. Non-pregnancy related infections, primarily HIV, account for 44 percent of maternal deaths, while 57 percent of deaths in children under five are believed to be HIV-related.

South Africa's prevention of mother-to-child HIV transmission (PMTCT) programme was belatedly launched in 2002 after a protracted legal battle between the government and Treatment Action Campaign, an AIDS lobby group.

However, the prevention effort has been dogged by poor leadership and a lack of integration into other maternal and child health interventions. "The legacy of a vertical response has created many conflicts that will be difficult to resolve," the authors commented.

The employment of thousands of lay counsellors in antenatal clinics increased the coverage of HIV testing to almost 70 percent of pregnant women by 2008, yet only 60 percent of those who tested HIV-positive, and 45 percent of their babies, received the antiretroviral drug, nevirapine, to reduce the risk of transmission.

Only about 10 percent of babies received postnatal care, and the rate of exclusive breastfeeding until six months - the safest option for HIV-positive mothers who did not have access to formula milk - was below 10 percent, the third lowest in Africa.

The Lancet authors estimated that achieving 95 percent PMTCT coverage and improving infant feeding practices could save the lives of 37,200 children a year and put South Africa on track to reach the MDG target for child mortality.

The cost of achieving this, along with better availability of basic neonatal care, was estimated at US$1.57 billion, or 24 percent of the public health budget, which the authors described as "affordable".

They emphasized that "The key gap is leadership and effective implementation at every level of the health system."

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