In SA, antenatal care is literally the difference between life and death
Often, access to appropriate care for pregnant women and girls can be as simple, or as complicated, as adequate transport
In 2014, Amnesty International released a report on the barriers that prevented pregnant women and girls accessing timely antenatal care in SA. Four years on, a new review of maternal mortality in the country has found that many of these barriers remain.
Antenatal care is crucial to any pregnant woman because it screens for complications that may develop during pregnancy which, left untreated, could put the mother and baby in danger.
Amnesty International’s 2014 report, “Struggle for maternal health”, based on research in Mpumalanga and KwaZulu-Natal, highlighted that too many women and girls were dying needlessly in SA during pregnancy or shortly after giving birth.
Some things have improved since then. Currently, the South African government recommends that women and girls begin their antenatal care visits from 14 weeks into their pregnancies, but most only seek antenatal care after 20 weeks. Appointments are free of charge and, since April 2017, the government increased the number of appointments from four to eight. Nearly all women receive at least one visit, and the number of maternal deaths has reduced significantly since 2014.
A large part of the problems women and girls experience in accessing antenatal care are linked to the lack of adequate sexual education and access to information in communities. The Amnesty report revealed that the government had failed to ensure they receive this education
However, a 2018 expert review of maternal deaths between 2014 and 2016 has again found a lack of antenatal care to be a key contributory factor in maternal deaths in the country. A total of 3,697 women and girls are reported to have died of pregnancy-related causes during this period. A quarter of the deaths were linked to late or no antenatal care.
The report found that barriers to accessing antenatal care include high transport costs, a lack of privacy and informed consent — particularly in HIV testing — and a lack of information. The high expense and a lack of transport options made antenatal care a luxury many pregnant women and girls could not afford.
Some had to use private transport to take them to their antenatal appointments, which means choosing between their families eating or them accessing antenatal care. Four years on, in Mpumalanga, a health care worker who did not want to be named has told us that transport remains one of the biggest challenges the women face.
Ambulances often arrive late, especially in rural areas, which can result in grave complications for the women giving birth.
In KwaZulu-Natal, the situation is slightly better as the community now has government transport to take them to the hospital from their local health care facility for appointments.
A local NGO volunteer says the service runs on specific days and those who require it have to book it. She said this is an improvement from four years ago, but ambulances are still unreliable, forcing women to pay for private transport in emergencies. “If you call an ambulance now, in the late afternoon, it will only come tomorrow morning,” she said.
Another finding of Amnesty’s 2014 report was a widespread fear that healthcare workers would disclose a pregnant patient’s HIV status, which resulted in many of the pregnant women and girls staying away from antenatal care.
Many women and girls incorrectly understood HIV tests to be a compulsory part of their antenatal care. This points to a lack of information, which the government must provide. This is a concerning breach of their right to informed consent and has the serious consequence of discouraging them from seeking care that is vital for them and their unborn babies.
A large part of the problems women and girls experience in accessing antenatal care are linked to the lack of adequate sexual education and access to information in communities. The Amnesty report revealed that the government had failed to ensure they receive this education. It also revealed that healthcare workers are not adequately trained to provide this information.
Although the government has taken steps to reduce the high maternal mortality rate, the challenges that pregnant women and girls face are underpinned by one important factor: gender inequality.
The challenge is even greater for the women and girls who want to terminate their pregnancies, as only 7% of SA’s 3,880 health facilities offer termination of pregnancy services, despite the government’s obligation to do so under international human rights law.
“Struggle for maternal health” was part of Amnesty International’s submission at SA’s review at the UN before the committee on economic, social and cultural rights in October. Although the committee did not delve into the maternal health aspect of SA’s challenges, it highlighted the profound inequalities in SA’s health system and called for National Health Insurance(NHI) to be expedited.
Quality, equitable healthcare is not only important for communities as a whole but also ensures that women, including those living with HIV, have access to the knowledge and medical attention they need. The NHI must deliver adequate health cover, especially on reproductive health, for vulnerable pregnant women and girls.
• Mohamed is executive director of Amnesty International SA.