Mothers and children in South Africa are dying in alarming numbers. Far from being on track to meet the Millennium Development Goal (MDG) of reducing child mortality by two-thirds, the country is among only a dozen worldwide where child deaths are rising.

In 2000, South Africa committed to eight MDGs set by the UN, which included reducing child and maternal mortality and reversing the spread of HIV/AIDS by 2015.

And yet, every year 20,000 babies are stillborn and another 22,000 die within the first month of their lives. In total, at least 75,000 children die before their fifth birthday, while 1,600 mothers die due to pregnancy or childbirth complications, according to a report on infant, child and maternal mortality, released at a conference on perinatal care in Johannesburg this week.

The report, Every Death Counts, produced jointly by the Department of Health, the Medical Research Council and the University of Pretoria, asserts that HIV/AIDS is one of the main reasons South Africa has failed to reduce its child mortality rates, while other countries with similar gross national incomes, such as Brazil and Mexico, are on track to meet the MDG.

The authors estimate that more than a third of maternal and child deaths in South Africa are AIDS related. Other factors are poor quality of care during childbirth, failure to prevent and treat childhood infections such as diarrhoea and pneumonia, and poor nutrition and living conditions associated with poverty.

"We have the solutions to save lives but they are not reaching those in most need, or they are not being implemented with the quality needed," the report noted. The authors estimated that at least 40,200 babies and children could be saved every year if government policies and programmes already in place were better implemented and were reaching the entire population.

In more than half the deaths, the authors identified "modifiable factors", such as lapses in both the coverage and quality of care mothers and children received at health facilities.
In the case of HIV/AIDS interventions, the report highlighted the need for universal testing of pregnant women, implementation of the health department's recent commitment to switch to more effective dual antiretroviral (ARV) therapy for the prevention of mother-to-child transmission (PMTCT), and PCR testing, which can detect HIV in infants under 18 months, of HIV-exposed infants at six weeks of age.

According to health department figures, 41 percent of the more than one million women who attended antenatal clinics in 2006 were never tested for HIV, while antenatal HIV prevalence figures indicate that just less than a third of those women would have been HIV positive.

Not only did these women miss the opportunity of receiving the ARV drugs that would have reduced the likelihood of infecting their babies, they did not receive treatment for their HIV infection either. In the majority of maternal deaths, the HIV status was unknown.

Children born to HIV-positive mothers are three times less likely to survive, regardless of the infant's HIV status. Their survival becomes even more precarious if the mother dies, said Mickey Chopra of the Medical Research Council, one of the authors of the report and a presenter at the conference.

"As much as we focus on PMTCT, we must keep mothers alive to raise their children," said Dr Mitchell Besser, founder of mothers2mothers (m2m), a non-governmental organisation that runs mentoring and support programmes for HIV-positive pregnant women and new mothers in four African countries.
Besides poor uptake of HIV testing, Besser identified several other reasons for South Africa's high infant mortality rate, including lack of education and support of HIV-positive mothers in making the best infant-feeding choices, insufficient testing and monitoring of HIV-exposed babies, and too few nurses and midwives.

"We keep giving more and more jobs to nurses," Besser told conference delegates. "Their job keeps getting bigger and bigger, but the number of nurses doesn't."

The m2m initiative aims to relieve some of the pressure on clinical staff by training HIV-positive mothers to mentor new mothers and pregnant women infected with HIV.

An evaluation of the programme by the Population Council, an international non-profit organisation, found that women who had received education and support through m2m were more likely to disclose their status, accept PMTCT treatment and exclusively formula- or breast-feed, which have all been proven to reduce the likelihood of mother-to-child infection.

HIV interventions during pregnancy and birth are fairly widely available in South Africa, but the report points to a drop in such interventions in the crucial period soon after birth. Chopra said HIV-infected infants deteriorated so quickly that "even testing infants with PCR at six weeks may be too late". He recommended asking mothers and babies to return for checkups and PCR testing a week after birth.

PCR testing of infants was only recently adopted in South Africa and is still rolling out. Precious Robinson, the health department's national PMTCT manager, described Chopra's recommendation as "not feasible", and said limited laboratory capacity already meant that in some provinces it could take up to four weeks to receive the results of a PCR test.

"Mothers can collect the results when they come for their 10 week visit," she told IRIN/PlusNews.

Chopra responded that "Many kids who can benefit from early diagnosis and treatment will have died by the time they receive test results."

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