title: Causes and avoidable factors in maternal death due to cesarean-related hemorrhage in South Africa.
abstract: OBJECTIVE
  To describe risk factors, clinical events, and avoidable factors in cases of maternal death due to bleeding during and after cesarean delivery.
  
  
  METHODS
  A retrospective study was undertaken of the clinical records of women who delivered in seven hospitals in Johannesburg, South Africa, between January 2013 and December 2014. Maternal deaths due to cesarean-related hemorrhage during or within 42days of cesarean delivery at 24weeks or more were selected. Case records were audited using quantitative techniques to determine the events leading up to death.
  
  
  RESULTS
  There were 123 251 deliveries and 17 maternal deaths due to bleeding during or after cesarean (3.2 deaths per 10 000 deliveries). Risk factors included previous cesarean delivery, preoperative anemia, and placental abruption. Uterine atony and surgical trauma were the main causes of bleeding. Five (29%) women died before the cause of bleeding was found. Avoidable factors included delays in the recognition and management of shock. Thirteen (76%) women died within 48hours of the cesarean procedure.
  
  
  CONCLUSIONS
  Deaths due to bleeding during and after cesarean have multifactorial causation. Maternal healthcare systems must be strengthened, with attention to the knowledge and skills of health workers. This requires increased clinical vigilance, a rapid effective response to obstetric hemorrhage and shock, and overall health system strengthening.
authors.affiliation: Wits Obstetrics and Gynaecology Clinical Research Division, University of the Witwatersrand, Johannesburg, South Africa. Electronic address: smaswime@gmail.com.
authors.forename: Salome
authors.initials: S
authors.lastname: Maswime
authors.affiliation: Wits Obstetrics and Gynaecology Clinical Research Division, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Eckhart
authors.initials: E
authors.lastname: Buchmann
mesh_terms: D000293:Adolescent; D000328:Adult; D002585:Cesarean Section / Q000009:adverse effects*; D002983:Clinical Competence; D005260:Female; D006801:Humans; D008428:Maternal Mortality; D018743:Perinatal Care; D006473:Postpartum Hemorrhage / Q000453:epidemiology* / Q000209:etiology / Q000401:mortality; D011247:Pregnancy; D012307:Risk Factors; D013019:South Africa / Q000453:epidemiology; D055815:Young Adult
keywords: Bleeding during and after cesarean; Cesarean delivery; Maternal mortality; Postpartum hemorrhage