title: The importance of cardiovascular pathology contributing to maternal death: Confidential Enquiry into Maternal Deaths in South Africa, 2011-2013.
abstract: OBJECTIVE
  Cardiac disease is emerging as an important contributor to maternal deaths in both lower-to-middle and higherincome countries. There has been a steady increase in the overall institutional maternal mortality rate in South Africa over the last decade. The objectives of this study were to determine the cardiovascular causes and contributing factors of maternal death in South Africa, and identify avoidable factors, and thus improve the quality of care provided.
  
  
  METHODS
  Data collected via the South African National Confidential Enquiry into Maternal Deaths (NCCEMD) for the period 2011-2013 for cardiovascular disease (CVD) reported as the primary pathology was analysed. Only data for maternal deaths within 42 days post-delivery were recorded, as per statutory requirement. One hundred and sixty-nine cases were reported for this period, with 118 complete hospital case files available for assessment and data analysis.
  
  
  RESULTS
  Peripartum cardiomyopathy (PPCM) (34%) and complications of rheumatic heart disease (RHD) (25.3%) were the most important causes of maternal death. Hypertensive disorders of pregnancy, HIV disease infection and anaemia were important contributing factors identified in women who died of peripartum cardiomyopathy. Mitral stenosis was the most important contributor to death in RHD cases. Of children born alive, 71.8% were born preterm and 64.5% had low birth weight. Seventy-eight per cent of patients received antenatal care, however only 33.7% had a specialist as an antenatal care provider. Avoidable factors contributing to death included delay in patients seeking help (41.5%), lack of expertise of medical staff managing the case (29.7%), delay in referral to the appropriate level of care (26.3%), and delay in appropriate action (36.4%).
  
  
  CONCLUSIONS
  The pattern of CVD contributing to maternal death in South Africa was dominated by PPCM and complications of RHD, which could, to a large extent, have been avoided. It is likely that there were many CVD deaths that were not reported, such as late maternal mortality (up to one year postpartum). Infrastructural changes, use of appropriate referral algorithm and training of primary, secondary and tertiary staff in CVD complicating pregnancy is likely to improve the outcome. The use of simple screening equipment and point-of-care testing for early-onset heart failure should be explored via research projects.
authors.affiliation: Department of Obstetrics and Gynaecology, Maternal and Foetal Medicine, Steve Biko Academic Hospital, University of Pretoria, South Africa; National Committee for the Confidential Enquiry into Maternal Deaths, South Africa Priya.Soma-Pillay@up.ac.za.
authors.forename: Priya
authors.initials: P
authors.lastname: Soma-Pillay
authors.affiliation: Department of Obstetrics and Gynaecology, Tembisa Hospital, Tembisa, South Africa; National Committee for the Confidential Enquiry into Maternal Deaths, South Africa.
authors.forename: Joseph
authors.initials: J
authors.lastname: Seabe
authors.affiliation: Hatter Institute for Cardiovascular Research in Africa, and IDM, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa; Soweto Cardiovascular Research Unit, University of the Witwatersrand, Johannesburg, South Africa; Inter-Cape Heart Group, Medical Research Council South Africa. karen.sliwa-hahnle@uct.ac.za.
authors.forename: Karen
authors.initials: K
authors.lastname: Sliwa
mesh_terms: D000293:Adolescent; D000328:Adult; D002319:Cardiovascular System / Q000473:pathology*; D002423:Cause of Death; D002648:Child; D003906:Developing Countries; D005260:Female; D006801:Humans; D063130:Maternal Death / Q000706:statistics & numerical data*; D008428:Maternal Mortality; D011247:Pregnancy; D011249:Pregnancy Complications, Cardiovascular / Q000453:epidemiology* / Q000473:pathology; D013019:South Africa / Q000453:epidemiology