South Africa has extremely high maternal mortality levels. This is true when compared with developed countries as well as other developing countries.
According to the World Health Organisation, for every 100,000 live births in the country in 2015, 138 women died due to pregnancy and childbirth complications. In Sweden, fewer than five women die for every 100,000 live births. In Brazil, the estimate is 44 women for every 100,000 live births.
Many of these deaths are preventable. And in South Africa – unlike many other developing countries – women mostly give birth in health-care facilities and visit antenatal clinics before they give birth. So why are the maternal mortality rates so high?
Earlier research has shown many women attend antenatal care for the first time too late in their pregnancies. This is due to:
overburdened clinics, resulting in many being turned away without help;
bad treatment by health-care workers, resulting in women devaluing the service;
their fear of testing HIV positive and the associated stigma; and
their cultural beliefs – that they may be bewitched by jealous neighbours or friends.
But our research shows that many women visit antenatal care clinics late because they discover they are pregnant late into their pregnancies.
Why women avoid antenatal clinics
Antenatal care services are mostly provided at community clinics that also provide a variety of general and primary health-care services to the community. These include care for HIV, TB and lifestyle diseases. These clinics tend to be busy and staff are often overburdened and overworked. All patients, including pregnant women, often have to wait for a long time before being seen by a nurse or doctor.
We interviewed women at public health-care facilities, including hospitals and birth facilities, in an urban area in the Western Cape province shortly after they had given birth.
More than a quarter of the women interviewed went to the clinic late into their pregnancies. Women who went to the clinic for the first time when they were five months pregnant were classified as attending a clinic late. But if attending an antenatal clinic at or after three months of pregnancy was considered late – attending after the first trimester is usually considered late – almost four in five women said they went late.
More than half of the women who said they sought antenatal care late did not go to the clinic early enough because they realised quite late that they were pregnant. Some said they purposefully postponed the visit. And more than two-thirds of the women who went late said nothing about the clinic would have made them go earlier.
The study showed that women who went late were more likely than those who went early to not have completed high school. Women who went late were also more likely to be poor. And compared with those women who attended clinics early into their pregnancies, these women were also more likely to say they consumed alcohol while they were pregnant.
We did not find evidence to show that late attendance was related to travel costs to access antenatal care at free public clinics.
But the relationship between poverty, education and general vulnerable circumstances is complex. While our research shows that women who attend antenatal care clinics later are likely to be poorer and have less education than women who attend early, we cannot say this is necessarily true for all poor or less-educated women. But poverty and lower education levels may make it more difficult for people to make the best choices about when to seek health care.
Why early antenatal visits are important
The World Health Organisation recommends at least four visits to an antenatal clinic during pregnancy. Although South African women almost make this target, their late attendance has an impact on the ability of the health-care system to influence their health and that of their babies.
Attending an antenatal clinic early in pregnancy is important for two reasons.
First, if pregnant women attend the clinics in the first three months of their pregnancy, HIV can be detected early and they can begin treatment. This makes it less likely that their babies will contract HIV. It also helps to support their own immune systems, which decreases the chance for infections before or after birth.
HIV is the biggest contributor to maternal deaths in South Africa. Almost a third of pregnant women who visit antenatal clinics in South Africa are HIV-positive.
Second, early attendance allows doctors to treat and manage other treatable health conditions that the mother-to-be may develop. These include high blood pressure and anaemia, which are also major risk factors for maternal deaths.
How pregnancy policy must change
If late pregnancy recognition is one of the major reasons for late attendance, what does this mean for policy about pregnancy care in South Africa?
There are two policy changes that could rectify this.
First, the National Department of Health needs to make it easier for women to recognise pregnancy. Urine pregnancy tests should be as widely available as condoms.
If women realised that they were pregnant sooner it would improve early antenatal care attendance and enable them to make more informed choices. For example, they would have time to consider an abortion in the case of an unplanned pregnancy.
Second, the way contraception is provided at clinics has to be reconsidered. Four in five women in our study said they had an unplanned pregnancy. The current system, where women can receive contraceptives at clinics, does not have the intended effect of preventing pregnancies. This could be due to the large focus on HIV prevention, which may limit some of the policy attention provided to contraception.
If this system were changed, women would be able to make better choices for themselves and their children.
Implementing these measures could go a long way to improve maternal health and ensure fewer children grow up without their mothers.