Maternal Deaths Before and During the COVID-19 Pandemic: Causes and Avoidable Factors in a Tertiary Hospital in South Africa

Abstract

Aim: To determine the institutional maternal mortality ratio (iMMR) and avoidable factors (AVFs) before and during the COVID-19 pandemic (COVID-19-P) in a tertiary hospital in South Africa. Methods: This was a retrospective cross-sectional study. We reviewed medical records to compare iMMR and associated AVFs two years before (March 2018 - February 2020) and two years during (March 2020 - February 2022) COVID-19-P. Results: Fifty-eight maternal deaths (MDs) were recorded but available data was for 57 (35 before and 22 during COVID-19-P). The highest iMMR per 100,000 live births over a 12- month period was 329.1 before and 201.8 during COVID-19-P. The mean ages were 31.0  6.9 and 31  6.2 years, p=0.822 before and during COVID-19-P, respectively. During COVID-19-P, 40.9% (9/22) were diagnosed with COVID-19. Before and during the pandemic, 71.4% (25/35) and 68.2% (15/22) p=1.0 were admitted into an intensive care unit (ICU), respectively, with corresponding 71.4% (25/35) and 50% (11/22), p=0.026 requiring mechanical ventilation. There was a significant difference in the primary causes of death (p=0.009) for the two periods, with preeclampsia with severe features (22.9%, 8/35) being the leading cause before COVID- 19-P compared to COVID-19 (31.8%, 7/22) during the pandemic. AVFs related to healthcare professionals were the most common occurring in 22/35 and 12/22 of the women who died before and during COVID-19-P, respectively. Before COVID-19-P, the most frequent patient-, healthcare professional-, and administrative-related AVFs were failure to book for antenatal care, administration of wrong treatment, and lack of ICU/high care bed spaces. During COVID-19-P, the most common patient-, healthcare worker- and administrative-related AVFs were delay in seeking medical treatment, lack of critical care skills, and unavailability of ICU/high care spaces. iv Conclusion: iMMR was lower during than before COVID-19-P. AVFs related to healthcare professionals were the most common.