Effect of Human Immunodeficiency Virus Treatment on Maternal Mortality at a Tertiary Center in South Africa A 5-Year Audit

OBJECTIVE: To review facility-based maternal deaths at a tertiary-level center in Johannesburg, South Africa, during a 5-year period (2003 to 2007) and to investigate the proportion of deaths attributable to human immunodeficiency virus (HIV), the etiology of deaths, and the effects of antiretroviral treatment introduced in late 2004. METHODS: Patient case files, birth registers, death certificates, and mortality summaries were reviewed. Cause of death was assigned through clinical case discussion. Annual maternal mortality ratios were calculated and disaggregated by HIV status. RESULTS: During the 5-year period, 106 maternal deaths occurred out of 36,708 births (facility-based maternal mortality ratios 289/100,000 live births, 95% confidence interval [CI] 237-349/100,000). In 72% of cases, HIV status was known (76/106), with the majority being HIV-infected (78%, 59/76). Among HIV-infected women, only two had initiated antiretroviral treatment, and 70% of deaths were HIV-related (41/59), mainly from tuberculosis (21) and pneumonia (12). Direct obstetric causes of death such as hypertension and pregnancy-related sepsis predominated in women who were HIV-negative or of unknown status (48.9%, 23/47). Maternal mortality ratios in HIV-infected women were 776/100,000 (95% Cl 5911,000/100,000), 6.2-fold higher (95% Cl 3.6-11.4) than in HIV-negative women (124/100,000, 95% Cl 72-199/100,000). Changes in mortality over time were not detected. Although HIV testing increased 1.4-fold each year (95% CI 1.3-1.4) and estimated coverage of antiretroviral treatment for pregnant women reached 59.2% in 2007, levels remain suboptimal. CONCLUSION: In Johannesburg, HIV remains the major cause of maternal mortality despite integration of antiretroviral treatment into prenatal services. Maternal health services should target barriers to uptake of HIV treatment and care. (Obstet Gynecol 2009;114:292-9)