title: Declining maternal mortality in the face of persistently high HIV prevalence in a middle-income country.
abstract: OBJECTIVE
  To estimate maternal mortality ratio (MMR) and determine maternal death causes and trends in Greater Soweto, Johannesburg, South Africa.
  
  
  METHODS
  Cross-sectional study.
  
  
  METHODS
  Chris Hani Baragwanath Maternity Hospital (CHBMH) in Greater Soweto.
  
  
  METHODS
  Maternal deaths at CHBMH.
  
  
  METHODS
  Record review of maternal deaths from 1997 to 2012, using hospital death records, with denominator data from the district health information system and the hospital.
  
  
  METHODS
  Maternal mortality ratio per 100,000 live births, and causes of death classified as in the South African confidential enquiries.
  
  
  RESULTS
  There were 479 deaths, with a peak MMR of 139 in 2004 and a decline to 86 in 2012. Of 332 women tested, 245 (74%) were HIV-infected. Nonpregnancy-related infection (40%) was the most frequent cause of death, followed by hypertension (16%) and obstetric haemorrhage (13%). HIV infection rates in these groups were 92%, 30% and 61%, respectively. Previous caesarean section was associated with obstetric haemorrhage death (odds ratio [OR] 3.2, 95% confidence interval [95% CI] 1.7-6.0), maternal age ≥35 years with hypertension death (OR 2.2, 95% CI 1.2-3.7) and antenatal anaemia with nonpregnancy-related infection death (OR 4.0, 95% CI 2.3-6.9), compared with other causes of death.
  
  
  CONCLUSIONS
  There is evidence of a decline in MMR since HIV treatment for pregnant women was introduced in 2004. Previous caesarean section, advanced maternal age, and anaemia were associated with death from obstetric haemorrhage, hypertensive disorders of pregnancy and nonpregnancy-related infections, respectively. MMR may be further reduced with accelerated initiation of HIV treatment during pregnancy.
authors.affiliation: Department of Obstetrics and Gynaecology, Chris Hani Baragwanath Academic Hospital and University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: E J
authors.initials: EJ
authors.lastname: Buchmann
authors.forename: C N
authors.initials: CN
authors.lastname: Mnyani
authors.forename: K A
authors.initials: KA
authors.lastname: Frank
authors.forename: M F
authors.initials: MF
authors.lastname: Chersich
authors.forename: J A
authors.initials: JA
authors.lastname: McIntyre
mesh_terms: D000293:Adolescent; D000328:Adult; D000740:Anemia / Q000453:epidemiology; D002423:Cause of Death; D002585:Cesarean Section; D003430:Cross-Sectional Studies; D003906:Developing Countries / Q000706:statistics & numerical data*; D005260:Female; D015658:HIV Infections / Q000150:complications / Q000453:epidemiology*; D006801:Humans; D046110:Hypertension, Pregnancy-Induced / Q000401:mortality*; D007239:Infections / Q000401:mortality*; D008428:Maternal Mortality / Q000639:trends*; D006473:Postpartum Hemorrhage / Q000401:mortality*; D011247:Pregnancy; D015995:Prevalence; D012307:Risk Factors; D013019:South Africa / Q000453:epidemiology; D055815:Young Adult
keywords: Human immunodeficiency virus in pregnancy; South Africa; maternal mortality; middle-income country; previous caesarean section