Declining maternal mortality in the face of persistently high HIV prevalence in a middle-income country.

Objective: To estimate maternal mortality ratio (MMR) and determine maternal death causes and trends in Greater Soweto, Johannesburg, South Africa.

Design: Cross-sectional study.

Setting: Chris Hani Baragwanath Maternity Hospital (CHBMH) in Greater Soweto.

Population: 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.

Main Outcome Measures: 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.

Conclusion: 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.