title: Increased Access to Antiretroviral Therapy Is Associated with Reduced Maternal Mortality in Johannesburg, South Africa: An Audit from 2003-2012.
abstract: OBJECTIVE
  To assess the impact of expanded access to antiretroviral treatment (ART) on maternal mortality in Johannesburg, South Africa between 2003 and 2012.
  
  
  METHODS
  Audit of patient files, birth registers and death certificates at a tertiary level referral hospital. Cause of death was assigned independently, by two reviewers. We compared causes of deaths and the maternal mortality ratios (MMR, deaths/100,000 live births) over three periods corresponding to changes in government policy on ART provision: period one, 2003-2004 (pre-ART); period two, 2005-2009 (ART eligibility with CD4 count <200cells/μL or WHO stage 4 disease); and period three, 2010-2012 (eligibility with CD4 count <350 cells/μL).
  
  
  RESULTS
  There were 232 deaths and 80,376 deliveries in the three periods. The proportion of pregnant women tested for HIV rose from 43.4% in 2003 to 94.6% in 2012. MMR was 301, 327 and 232 in the three periods, (p = 0.10). The third period MMR was lower than the first and second combined (p = 0.03). Among HIV-positive women, the MMR fell from 836 in the first time period to 431 in the third (p = 0.008) but among HIV negative women it remained unchanged over the three periods, averaging 148. Even in the third period, however, the MMR among HIV-infected women was 3-fold higher than in other women. Mortality from direct obstetric causes such as hemorrhage did not decline over time, but deaths from tuberculosis and HIV-associated malignancy did. In 38.3% of deaths, women had not attended antenatal care.
  
  
  CONCLUSIONS
  Higher coverage of HIV testing and ART has substantially reduced MMR in this hospital setting. Though the gap in MMR between women with and without HIV narrowed, a third of deaths still remain attributable to HIV. Lowering overall MMR will require further strengthening of HIV services, increased antenatal care coverage, and improved care for obstetric emergencies at all levels of care.
authors.affiliation: Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.|Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Vivian
authors.identifier: http://orcid.org/0000-0003-2274-8581
authors.initials: V
authors.lastname: Black
authors.affiliation: Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Andrew D
authors.initials: AD
authors.lastname: Black
authors.affiliation: Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Helen V
authors.initials: HV
authors.lastname: Rees
authors.affiliation: Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Franco
authors.initials: F
authors.lastname: Guidozzi
authors.affiliation: Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Fiona
authors.initials: F
authors.lastname: Scorgie
authors.affiliation: Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Matthew F
authors.initials: MF
authors.lastname: Chersich
mesh_terms: D019380:Anti-HIV Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000188:drug therapy / Q000453:epidemiology; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D063130:Maternal Death / Q000517:prevention & control*; D008427:Maternal Health Services; D008428:Maternal Mortality / Q000639:trends*; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000401:mortality*; D011295:Prenatal Care; D013019:South Africa / Q000453:epidemiology; D062606:Tertiary Care Centers / Q000706:statistics & numerical data; D016387:Women's Health / Q000706:statistics & numerical data
chemical_list: D019380:Anti-HIV Agents