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OBJECTIVE: To audit trends in maternal mortality in the Peninsula Maternal and Neonatal Service (PMNS) over a 50-year period, with respect to rates and patterns of causation. DESIGN: Retrospective and prospective audit. SETTING: The PMNS, an integrated perinatal service composed of primary, secondary and tertiary facilities in Cape Town. Population All women giving birth in the area of the Cape Peninsula served by the PMNS over the 50-year period. METHODS: Data on maternal deaths were collected for 1953-2002 inclusive, from annual obstetric and gynaecological reports. Three triennia (1954-1956, 1981-1983 and 1999-2001) were selected for a detailed comparison of trends in rates and causes of death. MAIN OUTCOME MEASURES: Maternal mortality rates (MMRs). Causes of maternal deaths. RESULTS: Total deliveries increased from 7315 in 1953 to 27,575 in 2002. The MMR declined from 301 deaths per 100,000 deliveries in 1953 to 31.2 in the triennium, 1987-1989. From 1999, the MMR increased, reaching 112 in 2002. Comparing 1954-1956 (MMR of 253.9) with 1981-1983 (MMR of 43.8), there was a marked decline in the MMR related to hypertension (80.4 to 11.3), haemorrhage (50.8 to 4.2), abortion (55 to 4.2), suspected pulmonary embolism (25.4 to 2.8), pregnancy-related sepsis (8.5 to 4.2) and cardiac disease (21.2 to 2.8). Comparing 1981-1983 (MMR of 43.8) with 1999-2001 (MMR of 59.4), there was a decline in the MMR associated with abortion (4.2 to 0). The MMR for haemorrhage, suspected pulmonary embolism and cardiac disease remained the same. There was a slight increase in the MMR attributed to hypertension (11.3 to 14.5) and pregnancy-related sepsis (4.2 to 7.3). There was a marked increase in the MMR associated with non-pregnancy-related infections/AIDS (4.2 to 18.2). CONCLUSIONS: The MMR for all causes of maternal death declined significantly from 1953 to 1981 as a result of several interventions. From 1999, there has been a non-significant increase in MMR, predominantly due to the burden of HIV/AIDS-related mortality. [ABSTRACT FROM AUTHOR]

Objective: To determine whether the 17% decrease in the number of patients cared for at the Khayelitsha Midwife Obstetric Unit (MOU) between 1991 and 1994 could be ascribed to an increase in home deliveries., Method: Survey of Khayelitsha labour ward records, vaccination cards and family planning statistics at various clinics in Khayelitsha, Cape Town., Results: The prevalence of home deliveries in Khayelitsha during the study period was estimated at 8%. Between 1992 and 1994, the number of acceptors at family planning clinics in Khayelitsha increased by 89%., Conclusion: As the number of home deliveries had apparently remained static, it was unlikely that an increase in the former had been responsible for the observed decrease in Khayelitsha MOU patients. Other possible reasons for the decline, viz. (i) an increase in hospital deliveries; (ii) an increase in the number of patients returning to the so-called homelands to be delivered there; (iii) an increase in confinements by private doctors and midwives; and (iv) that patients had shunned the MOU, were equally unlikely. The decline in the number of patients cared for at Khayelitsha MOU between 1991 and 1994 was most likely due to the evident success of the local family planning programme.

Referrals for inadequate progress of labour from the Midwife Obstetric Units (MOUs) to the referral hospitals are responsible for a significant part (approximately 5%) of the workload of these institutions in the Peninsula Maternal and Neonatal Service Region in Cape Town. It is essential for the maintenance of community credibility in the MOUs that patients who develop complications are timely and speedily transferred to the appropriate referral hospital. A sample of 251 patients, who were transferred from the MOUs to the referral hospitals for inadequate progress of labour in the first half of 1992, was analysed. The study showed that midwives in the MOUs had largely adhered to the Departmental referral criteria for that potentially serious complication of labour and had kept excellent records. The referrals, in terms of eventual outcome for the patients and their infants, had been largely appropriate. Several areas of concern were identified. These included incomplete assessment of the stage of labour on admission and inadequate monitoring of the fetal heart in a number of patients. Provision of analgesia in labour was generally inadequate. Ambulance delay was disturbingly common. Recommendations for measures to redress these management deficiencies are presented.

The obstetric records of patients from Khayelitsha were examined to assess the efficiency of a system for the antenatal prevention of congenital syphilis, and to identify points of breakdown in the process. Seventy-seven (12.7%) of 607 mothers had serological evidence of syphilis, including 10 (32.3%) of 31 mothers who had received no antenatal care. Of 70 patients who required routine management, only 36 (51.4%) received 3 or more of the recommended 4 penicillin injections. Two main weaknesses in the system were identified. One was the centralisation of serological testing. This delayed results reaching the relevant unit, and was responsible for a high cumulative attrition of patients during the many stages necessitated by the centralised testing. The other was a 24.5% attrition of patients referred from the antenatal clinic to a separate sexually transmitted diseases clinic.

Objective: To compare maternal mortalities attributable to vaginal delivery, elective caesarean section (CS) and intrapartum CS., Design: The number of deaths associated with each method of delivery was ascertained among unselected and among low-risk women by detailed retrospective review of the case-notes of women who died after delivery. The frequency of each method of delivery throughout the study period was ascertained from the computer database and enhanced by analysis of the case-notes of unselected groups of women., Setting: The Peninsula Maternity Services (Cape Town) during the years 1975-1986 inclusive., Subjects: A total of 108 maternal deaths arising from 263,075 maternities provided accurate information. The relative frequency of vaginal and abdominal delivery was determined from the computer database. The ratio of elective CS to emergency prepartum CS to intrapartum CS was obtained by review of the first 200 operations in the years 1975, 1977, 1979, 1982 and 1984., Main Outcome Measures: (i) Mortality rates associated with the different methods of delivery in unselected women and in women who were healthy before surgery; (ii) mortality rates apparently attributable to the method of delivery., Results: The overall relative risk of mortality associated with caesarean section compared with vaginal delivery was 7 decreasing to 5 after the exclusion of women with medical or life-threatening antenatal complications (eg, haemorrhage, hypertension). The relative risk associated with intrapartum compared with elective sections was 2.3 decreasing to 1.4 after the exclusion of women with medical disorders or life-threatening complications. The relative risk of maternal mortality which was apparently attributable to intrapartum compared with elective sections was 1.7. However, the 95% confidence intervals of these values, even from this large data-set, are wide. Nevertheless, these rates are in broad agreement with an approximation derived from the British confidential enquiries into maternal deaths., Conclusion: The attributable relative mortalities of caesarean section compared with vaginal delivery and intrapartum compared with elective caesarean section are lower than the overall relative mortalities of these modes of delivery and are approximately 5:1 and 1.5:1 respectively. These data are crucially important in the decision to recommend elective caesarean section compared with trial of labour.

A total of 323 mothers was interviewed at home about 12 days after early discharge (within 48 hours after delivery) from maternity hospitals and midwife obstetric units. Their views concerning antenatal care, delivery and contraceptive advice were obtained as well as details about their problems at home with themselves and their babies. It is concluded that early discharge of suitably selected mothers and babies is safe.

A retrospective series of 18 patients with a cervical stump is presented. Of the 12 patients who were followed up, all but one had a clinical indication for cervicectomy. Elective cervicectomy 2-3 months after subtotal hysterectomy is recommended.

A prospective series of 307 patients who underwent laparoscopic sterilization on a day-case basis is presented. Of these, 196 patients attended for the 6-month and 117 for the 1-year follow-up visit. There were 5 Blacks, 197 Coloureds and 105 Whites. Sterilization was done by means of tubal cauterization (137), Hulka-Clemens clips (34) and Falope rings (136). Although 18% of patients were under 30 years old, 16% were 40 years of age or older. A marked tendency to low parity was evident, 43% of Coloureds and 90% of Whites being para 3 or less. The main operative problem was uterine perforation. Of the patients 17% were not discharged on the day of operation. By the 5th postoperative day 86% had returned to normal working activities. Significantly more postoperative abdominal pain was reported in the clip and ring groups. Seven pregnancies occurred in the series, 6 after tubal cauterization and 1 after the application of Falope rings. On patient was probably pregnant at the time of the operation. Most patients reported no change in libido at the 1-year follow-up visit, and in 20% libido was increased Mild pelvic infection was the only significant finding at the 6-month and 1-year follow-up visits. Apart from the disturbingly high pregnancy rate and the relatively large number of patients who were not discharged on the day of operaton, the sterilization programme has been most acceptable.

Major changes have occurred in the nature of the obstetric population under the care of the Department of Obstetrics and Gynaecology in Cape Town between 1974 and 1978. In the Coloured group, a settled population, these changes were: a decrease in the number of teenage deliveries, a shift from the very young to the older teenage patient, and a decrease in the number of elderly obstetric patients and of grand multiparas. Puerperal sterilization virtually doubled during this period. Similar trends in Black and White patients must be interpreted with caution since the former constitutes a shifting population and the latter are not representative of White obstetric practice in Cape Town. Family planning education and the greater acceptance of voluntary sterilization have contributed to the declining numbers of socially and obstetrically disadvantaged patients.

The first year of existence of the Peninsula Maternity and Neonatal Service (PMNS) is reviewed. Some 21000 deliveries per annum fall under the Service. The ethnic distribution in 1980 was 27% Black, 69% Coloured and 4% White. The perinatal mortality rates per 1000 births were 31,2 for Blacks, 29,4 for Coloureds and 15,0 for Whites, with an overall perinatal mortality rate for the PMNS of 29,2. The administration of the PMNS is described. The Midwife Obstetric Units are discussed under the following headings: function, workload, advantages, and continuing education. Research opportunities and the main problems in the PMNS are outlined.

A revised scheme of management of the third stage of labour was recently introduced in the Midwife Obstetric Units in Cape Town. Patients received synthetic oxytocin (Syntocinon; Sandoz) 5 IU intramuscularly with the delivery of the anterior shoulder and ergometrine maleate 0.5 mg intramuscularly after delivery of the placenta. A significant decrease in the incidence of postpartum haemorrhage and retained placenta was observed, warranting continuation of the new regimen.

A series of 19 non-virginal patients who sustained vaginal injuries during normal coitus is presented. Twelve were between 16 and 25 years of age and 5 were older than 45 years. All presented with profuse or prolonged vaginal bleeding. The initial diagnosis was frequently wrong because a history of injury was not forthcoming and visualization of the lesion was obscured by the bleeding. The possibility of such trauma should be kept in mind; digital examination confirms the diagnosis. Prompt surgical suturing under general anaesthesia is required to control the haemorrhage.

A total of 43 patients who had undergone laparoscopic tubal occlusion by means of bipolar cauterization underwent bilateral salpingectomy 6-30 months later. The macroscopic and microscopic changes in the fallopian tubes are described. Although 35 patients appeared to have occluded tubes on macroscopic examination, only 22 showed occlusion on microscopic examination.

During 1978-1983, 57 maternal deaths (23 in blacks, 32 in coloureds and 2 in whites) occurred among 131,288 deliveries (36,564 in blacks, 89,335 in coloureds and 5389 in whites) in the Peninsula Maternal and Neonatal Service, Cape Town. Data for whites were not analysed further. Maternal mortality rates (MMRs) were higher in blacks than in coloureds. Age- and parity-specific MMRs showed that black teenagers and primiparas and coloureds aged 20-34 years and of parity 2-4 had the lowest rates. Advanced age and grand multiparity had a much greater adverse effect in coloureds than in blacks. Eighteen per cent of deaths in blacks and 9% of those in coloureds were in unbooked patients. The main causes of death (obstetric and non-obstetric) in blacks were sepsis, abruptio placentae, eclampsia and pneumonia. In coloureds they were eclampsia, other manifestations of proteinuric hypertension, cardiac disease, sepsis, haemorrhage (grouped) and diabetes. Of those who died, 43% of blacks and 38% of coloureds had had a caesarean section. The perinatal mortality rate was 417 for blacks and 469 for coloureds. A number of avoidable factors were identified. Most, if not all, deaths occurred because simple perinatal rules were broken.

During the 5-year period 1976--1980 9 430 patients underwent tubal occlusion at Groote Schuur Hospital, Cape Town. Of these patients 24, or 2.5/1 000, became pregnant after the procedure. An analysis of the pregnancy rate for each method of tubal occlusion is reported. Bilateral tubal occlusion by laparotomy or falope rings has flow failure rate; cauterization has not.

The urgent need for an alternative to domiciliary delivery in Cape Town has been met by the development of midwife obstetric units (MOUs). These units are situated in suburbs with a high population density. They are staffed entirely by midwives and are linked by telephone to the base hospital. A flying squad service is available at the regional centre (the maternity block at Groote Schuur Hospital). Regular visits are made to the units by the medical staff. Strict criteria for delivery at the MOUs have resulted in a very low perinatal mortality rate, and the units have at the same time relieved the serious overcrowding in the teaching hospitals. The concept of the MOU is particularly suited to Africa and indeed to any developing country.

During the period 1957 - 1977 there were 421 deaths recorded in the gynaecological wards of Groote Schuur Hospital, Cape Town. Nearly 50% of the patients were Coloureds, 25% were Whites, and 14% were Blacks; in 14% the ethnic group was not stated. Seventy-four per cent were more than 40 years and 25% were more than 70 years of age. The causes of death in order of frequency were: malignant disease of the cervix (30%), malignant disease of the ovary (17%), incomplete abortion (15%), non-gynaecological conditions (11%), malignant disease of the corpus uteri (8%), intra-abdominal malignancy (6%), pulmonary embolism (3%), sepsis not associated with abortion (3%), malignant disease of the vulva (2%), and other conditions (5%). The six commonest causes of death varied in the three ethnic groups.

Over a 6-month period 265 white females aged under 24 years attending the Teenage Clinic of the Western Cape Region of the Family Planning Association were interviewed at their first visit; 81% were sexually active. The age of menarche and the parents' marital status were important parameters of socio-sexual behaviour. The earlier the menarche, the higher the prevalence of coitus at a younger age, and the shorter the interval between menarche and the first coitus. Young age at first coitus, in turn, was associated with a higher prevalence of multiple sexual partners and smoking, and a longer period of unprotected intercourse before attending the clinic than among those who first attempted intercourse at a later age. Of those who had first experienced coitus at under 17 years, 37% came from single-parent families, compared with 12% of those in whom coitus was delayed until over 19 years of age. The important health and educational implications are discussed.

The age and parity distributions of all black and coloured maternity patients whose babies were delivered by the Peninsula Maternal and Neonatal Service in Cape Town in 1974 were compared with those for the trienniums 1978 - 1980 and 1981 - 1983. The numbers and percentages of teenage pregnancies, grand multiparas and pregnancies in women greater than 34 years were analysed. Over the decade there was no change in these three demographic parameters among blacks. In contrast there was a marked decline in the percentage and number of grand multiparas and a slight decrease in the percentage of women over 34 years among the coloured patients. The prevention of teenage pregnancies must remain the major demographic priority in Cape Town.

Estimates of infant mortality suggest that the rate during the past 14 years for families living in Khayelitsha at present was approximately 130-160/1,000. In contrast, the infant mortality rate for infants born in Khayelitsha during 1986 was 50.3/1,000. The highest rates occurred in the post-neonatal period in 'squatter' families, infection being a common cause of death. Mortality rates should fall further with improved housing.

The number and nature of the calls received by the Cape Town Flying Squad Service during 1972 are compared with those received from 1954 to 1960. A threefold increase in the total number of calls received per year is related to a fall from 74% to 30% in calls connected with postpartum complications. Reasons for these changes are suggested.

Perinatal deaths and perinatal mortality rates in Cape Town for the period 1967--1977 have been analysed, and large differences were found between the various ethnic groups. In non-Whites stillbirths accounted for more than two-thirds of perinatal deaths in 1977, and in at least 75% of these fetal death preceded labour. Perinatal mortality rates must be considered together with the number of perinatal deaths if the true magnitude of the problem with regard to the various obstetric complications and procedures is to be appreciated. The main perinatal problems as they affect the infant were (i) during pregnancy--antepartum haemorrhage (especially abruptio placentae), intra-uterine growth retardaton, multiple pregnancy, proteinuric hypertension and unbooked status; (ii) during labour and delivery--preterm labour, stillbirths (especially before labour) and vaginal breech delivery; (iii) in the early neonatnal period--immaturity and respiratory distress and neonatal infection.

Total abdominal hysterectomy (TAH), the commonest major gynaecological operation performed at the Groote Schuur and Somerset Hospitals, is associated with considerable financial and social problems for the family. A retrospective series of 300 consecutive patients who had undergone TAH is presented. This series was analyzed for factors influencing the prevalence of wound haematoma, sepsis and dehiscence, pain and decreased mobility, the main parameters of postoperative morbidity. The four factors found to be important in minimizing postoperative complications of TAH were: (i) the experience of the surgeon; (ii) the use of the Pfannenstiel rather than the subumbilical midline incision; (iii) closure of the skin with Dermalon rather than with black silk; and (iv) drainage of the wound.

The Peninsula Maternity and Neonatal Service (PMNS) was established on 1 January 1980 as a result of the regionalization of obstetric and neonatal services in the Cape Peninsula. Some 20000 deliveries per annum occur in the 5 maternity hospitals and 3 Midwife Obstetric Units (MOUs) under the aegis of the PMNS. As part of the reorganization of the service the booking and referral criteria have been revised, taking into account the function of the Groote Schuur Hospital Maternity Block as the high-risk unit. The concept of risk in perinatology is discussed. The booking and referral criteria are detailed under the headings of booking criteria for hospital and for MOUs and referral criteria from the MOU to hospital -- antenatally, in labour, in the puerperium and for neonatal problems.

In the period 1953 - 1977 there were 223 maternal deaths among 291 800 patients delivered in hospitals under the aegis of the Department of Obstetrics and Gynaecology of the University of Cape Town. A sudden decrease in the maternal mortality rate to below 100/100,000 deliveries occurred in 1956, largely due to the greater use of the obstetric 'flying squad'. Since 1975 maternal mortality rates have been available for the various ethnic groups. For the period 1975 - 1977 the rates were 69/100,000 for Blacks, 40/100,000 for Coloureds and 27/100000 for Whites. Of the deaths, 48% occurred in women aged 21 - 30 years and 29% in those aged 35 years or more. While 28% of deaths were associated with the first pregnancy, grand multiparity (parity 5 or more) accounted for 39%. Nearly half of the patients who died were unbooked. The 7 commonest causes (grouped) of maternal deaths (obstetric as well as non-obstetric) were, in rank order: proteinuric hypertension, haemorrhage, cardiac disease, pulmonary embolism, sepsis, trauma and anaesthetic complications. Proteinuric hypertension is the most important obstetric problem in Cape Town, in terms of numbers of patients, maternal and perinatal deaths, and socio-economic implications for the community. Slightly more than 33% of the infants whose mothers died also succumbed. Major avoidable factors associated with maternal deaths were booking status, grand multiparity, cardiac disease and late or incorrect use of the 'flying squad'.

The satellite 'city' of Khayelitsha lies some 40 km south-east of the centre of metropolitan Cape Town. The first phase of the development, Town 1, including a large 'squatter' area, accommodates approximately 150,000 people at present. It is envisaged that ultimately the entire 3,200 ha site will house between 250,000 and 350,000 people. In order to obtain useful planning information for future community obstetric and neonatal health care services, a survey of all births within the Peninsula Maternal and Neonatal Service (PMNS) during 1986 was undertaken. Of a total of 2,113 mothers from Khayelitsha, 2,000 (94.7%) gave birth to a live singleton infant. The mean maternal age was 26.2 years, 15.1% of mothers being under 20 years of age. The mean parity was 3.03, and 18.3% of mothers were having their first baby. Only 3.1% of mothers booked early (in the first trimester); however, 91.9% were booked before delivery. The average number of prenatal visits was 3. The largest proportion of mothers (43.1%) delivered at the Heideveld midwife obstetric unit (MOU). There was an overall pre-term rate of 7.6%, while 8.8% of infants were of low birth weight (LBW) (less than 2,500 g). In addition, 51.4% of the LBW infants were born at term. The mean birth weight was 3,160 g. The largest proportion of mothers (53.6%) were residents of the 'squatter' area. No statistically significant differences in obstetric features, maternal characteristics and pregnancy outcome were discernible between the squatter, site-and-service, and core housing areas of Khayelitsha, with the exception of higher maternal weight, earlier booking and more antenatal visits in the group from the core housing area.

The durations of the various stages of normal labour in White patients delivered at Mowbray Maternity Hospital, Cape Town, have been estimated for parity groups 1, 2, 3 and 4 and over. A significant correlation between age and the duration of the second stage was found in the para 2 group (r = 0,23, P less than 0,05). Previous abortions, marital status and oxytocic augmentation had no significant effect. The mean durations of the 1st and 2nd stages in primigravidas were significantly longer than in multigravidas. The upper limits of normal for the durations of the 1st and 2nd stages and the duration of the active phase were calculated. The mean duration of the 3rd stage was approximately 5 minutes.