Causes and avoidable factors in maternal death due to cesarean-related hemorrhage in South Africa

Objective: To describe risk factors, clinical events, and avoidable factors in cases of maternal death due to bleeding during and after cesarean delivery. Methods: A retrospective study was undertaken of the clinical records of women who delivered in seven hospitals in Johannesburg, South Africa, between January 2013 and December 2014. Maternal deaths due to cesarean-related hemorrhage during or within 42 days of cesarean delivery at 24 weeks or more were selected. Case records were audited using quantitative techniques to determine the events leading up to death. Results: There were 123 251 deliveries and 17 maternal deaths due to bleeding during or after cesarean (3.2 deaths per 10 000 deliveries). Risk factors included previous cesarean delivery, preoperative anemia, and placental abruption. Uterine atony and surgical trauma were the main causes of bleeding. Five (29%) women died before the cause of bleeding was found. Avoidable factors included delays in the recognition and management of shock. Thirteen (76%) women died within 48 hours of the cesarean procedure. Conclusion: Deaths due to bleeding during and after cesarean have multifactorial causation. Maternal healthcare systems must be strengthened, with attention to the knowledge and skills of health workers. This requires increased clinical vigilance, a rapid effective response to obstetric hemorrhage and shock, and overall health system strengthening. (C) 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).