Health and demographic surveillance sites contribute population-based data on maternal deaths in rural areas

To the Editor: Maternal mortality remains an important public health challenge in South Africa despite government initiatives to monitor and reduce maternal deaths.¹ In particular, the mandatory notification of maternal deaths, with rigorous investigation through the National Committee on Confidential Enquiries into Maternal Deaths, has been an important national intervention to quantify the problem and monitor trends. However, this system of enquiry is fundamentally health service-based, and data are collected largely through record review and notification forms submitted from the health facility where the death occurred.² The vital registration system offers another source of maternal death data, but reporting of deaths, particularly in rural under-resourced areas, is incomplete. While death registration has increased nationally from 54% in 1990 to 89% in 2000, only 78% of deaths were registered in rural Limpopo province in 2002.^3,4 In contrast, health and demographic surveillance sites (HDSSs), which collect household-level data on all births and deaths in a defined population, are able to identify maternal deaths that occur in the community. Moreover, this system provides an opportunity to interview those close to the deceased, using the verbal autopsy method, to gain an understanding of possible causes, as well as contributory and avoidable factors that led to the death.⁵

The Agincourt HDSS, located in the rural north-east of South Africa, is 1 of 3 such sites in the country (Dikgale DSS, University of Limpopo, and Africa Centre DSS, University of KwaZulu-Natal, are the other 2 sites). A review of maternal deaths occurring at this site between 2000 and 2005 indicates that 6 of the 26 deaths occurred outside of the health system/at home, and hence might have been missed by the existing notification system. This is a much higher proportion than the 2.8% reported nationally, albeit for a different time period.⁶ Given that women with least access to services are likely to be those whose deaths go undetected, the factors contributing to their deaths are likely also to go undocumented – and thus fail to inform local practice. Hence, the HDSS provides an additional source of data on maternal deaths that complements national facility-based data by offering a population-based perspective. High-quality data on maternal deaths from rural areas is especially important, given that these areas have the highest burden of mortality and the least reliable information.⁷ Health and demographic surveillance sites are able to capture this community experience effectively so that barriers to health service access, such as transport, finance and local culture, can be better understood and addressed in South Africa’s rural areas.