BLOEMFONTEIN, SOUTH AFRICA MARCH 11: (SOUTH AFRICA OUT) A newborn baby at the Kangaroo Mother Care Centre at Pelonomi Hospital on March 11, 2014 in Bloemfontein, South Africa. The Kangaroo Mother Care Centre helps women who deliver premature babies across the Free State province to take care of their babies until they are fully developed. Kangaroo care is a technique practiced on premature babies, wherein the infant is held, skin-to-skin, with an adult. The concept was initially developed to care for premature babies in areas where incubators are either unavailable or unreliable. (Photo by Conrad Bornman/Gallo Images/Getty Images)
A nurse at Livingstone Tertiary Hospital in Gqeberha, Eastern Cape, describes the hospital as a difficult and stressful place to work, citing corruption and poor governance as key factors behind medical stock-outs and inadequate maintenance of infrastructure.
“We have been struggling since the beginning of the year just with basic medical equipment. I am talking about needles. I am talking about syringes. I’m talking about IV bags, drips. Not to mention medication and patients having to be turned away because we don’t have medication or we don’t have medical equipment to perform certain procedures,” said *Zanele Ndoda.
She said staff members have to improvise because of the shortage of resources such as incubators, which meant premature babies had to be kept in boxes.
“This is just a daily routine — we have to improvise. When you report that you don’t have something or you don’t know how to do this procedure without [the necessary tools], you are told you’re a nurse and you need to improvise.”
The hospital’s maternal facilities was one of six health care facilities the Commission for Gender Equality investigated. The others were Cecilia Makiwane Hospital in Mdantsane, Frere Hospital in East London, Bisho Hospital, Dora Nginza Provincial Hospital in Zwide township in Gqeberha and St Elizabeth Mission Hospital in Lusikisiki.
The report was released last week, and comes as several provinces, particularly the Eastern Cape, are struggling to provide sufficient, quality healthcare services for women, despite government initiatives to advance gender equality and women’s health.
“The Eastern Cape is notably grappling with elevated rates of maternal and neonatal mortality,” the report says.
The Eastern Cape has 775 primary healthcare facilities, of which 733 are clinics and 42 community healthcare centres. It has 90 hospitals.
According to the District Health Information System, maternal mortality ratios in health facilities in the province increased from 106.1 in 2019 to 108.2 in 2020. Increases were also noted in the Northern Cape, while all other provinces reported decreases in the maternal mortality ratios during the reporting period.
At the Cecilia Makiwane Hospital, which caters for a population of 267 000 alongside the Frere Hospital, 17 maternal deaths per perennial problem identification problem (PPIP) and 15 maternal deaths per District Health Information System (DHIS) were recorded in the 2020 to 2021 fiscal year. This decreased in 2021 to 2022 to 11 maternal deaths in the PPIP and eight per DHIS, and increased in 2022 to 2023 to 13 maternal deaths in PPIP and 12 per DHIS.
The commission noted that the majority of deaths in 2020 and 2021 were attributed to the Covid-19 pandemic.
Neonatal deaths were flagged as concerns. From April 2020 to March 2021, there was a mortality rate of 14.3%, and in the following year it was 11%, but it increased again in April 2022 to March 2023 to 13.9%.
“These deaths were attributed to various causes, including maternal hypertension, spontaneous preterm births, infections and overcrowding in neonatal units,” according to the report.
But the commission lauded the Cecilia Makiwane Hospital for cleanliness, maintenance and adequate ventilation.
“It is state of the art in respect of its infrastructure and good government, and we wish the same could have been carried out throughout with other hospitals,” said Tsietsi Shuping, the acting head of legal services at the commission.
The report noted that overcrowding was prevalent across the six health facilities — Livingstone, Cecilia Makiwane, Frere, Bisho, Dora Nginza and St Elizabeth.
“While instances of overcrowding are not uncommon, deaths resulting from infections attributable to overcrowding should not be frequent,” the report says.
The report noted that Dora Nginza, a district hospital that has a bed capacity of 220, experienced overcrowding to an extent that patients slept on benches or shared beds.
“Further scrutiny has validated the challenging conditions within the maternity wards, revealing instances of postpartum patients being displaced due to bed shortages and some patients resorting to makeshift sleeping arrangements on floors or benches.”
There was also a consistent increase in the rate of early neonatal deaths and neonatal deaths in the facility from 2020 to 2023. This is despite it being “well maintained” in terms of building and floors, ventilation and general hygiene.
The Bisho Hospital has 205 beds for a population of 100 000 in the district. Regarding the quality of the facility, Shuping said: “There’s visible mould in the bathrooms, overall cleanliness concerns were noted, and there is lack of change in maintenance staff that exacerbate the issues, therefore necessitating and highlighting the need for improvement management of the facilities.
“We noted that the proximity of the isolation rooms to the neonatal ward pose infection risk … infectious units or wards shouldn’t be in close proximity to the wards that are providing services to the vulnerable, to children and mothers who just gave birth.”
The facility also had a staff shortage and limited resources: an inadequate number of beds resulted in long queues and strained medical services. Shuping said in some instances patients had to bring their own sheets, posing the risk of introducing infections.
While the facility met some standards, it fell short in providing health and reproductive services for women.
According to the report, in the 2021 and 2022 fiscal year, Bisho Hospital recorded one maternal death caused by a lower respiratory infection. Two other maternal deaths were reported in the following period.
“The occurrences of the death due to various causes highlights the importance of comprehensive healthcare and the need for appropriate medical interventions tailored to specific conditions to prevent mortality,” the report states.
From 2020 to 2023 the number of neonatal deaths increased: a total of 72 early neonatal deaths and 10 late neonatal deaths were reported.
Delivery among adolescents aged 10 to 19 also contributed to high rates of maternal and neonatal deaths, according to the report.
This was prevalent at St Elizabeth hospital.
“The high delivery rate among patients aged 10 to 14 years old is alarming. St Elizabeth hospital is rated fifth nationally and first in the province for sexual offences and rape cases and it is therefore concerning that despite these high numbers, there is no evidence of any steps taken by the hospital to report the cases of statutory rape to authorities,” the report said.
From 2020 to 2023, a total of 3 669 deliveries by 10 to 14 year olds were reported. Over the same period, the overall number of stillbirths was 306 and the deaths of babies aged up to six days was 151.
Frere Hospital was flagged as having “numerous deficiencies”. This included poor maintenance of infrastructure, poor ventilation, sanitation problems and improper waste disposal.
The hospital caters for about three million people, and was deemed to be a “prominent healthcare institution”. But the conditions were sub-standard.
“What we observed is that in the hospital, infrastructure displayed concerning maintenance issues. There are leaking roofs, mould, peeling paint and poor cleanliness,” Shuping said.
“The underground tunnels connecting the maternity ward exhibited hazards such as exposing electrical wires, [heightening] the risk of fire and electrocution as well.”
“While they pass the air conditioning [standard], we noted there are inconsistencies regarding functionality and obstruction of the windows, which compromise ventilation, contributing to the discomfort and potential infections.”
The Frere Hospital mother and child care unit was also overcrowded and there were extended waiting periods for women seeking to terminate pregnancies, which often led to the women resorting to dangerous backdoor abortions.
Maternal deaths decreased from 20 in 2021 and 2022, and to 16 in 2022 and 2023. The commission said these deaths were commonly attributed to pre-existing maternal conditions including respiratory, congenital heart and haematological diseases. Other causes of death were Aids and ectopic pregnancies.
There was a significant fluctuation in the early neonatal in-facility death rate.
According to the report, in June 2020, it was as high as 29.4% but in September 2022 it dropped to zero.
On average, the early neonatal death rates were lower than the late neonatal death rates from April 2020 to March 2023. These deaths were mostly attributed to immaturity-related conditions, but the fluctuations are an indication of change in healthcare practices and resources.
“The fluctuations in rates over time highlight the need for continuous monitoring and evaluation of healthcare services to identify areas for improvement and implement targeted interventions,” the report says.
The commission noted that overall the healthcare facilities in the Eastern Cape need better administration and governance, and that problems weren’t created by insufficient resources but that they were not being used correctly.
Ndoda, the Livingstone hospital nurse, said that security for staff and patients, as well as electricity faults, had to be dealt with as a matter of priority.
“We use a lot of electricity because there’s a lot of machinery, ventilators, monitors, everything keeping the patient alive, and sometimes wall sockets are not working. We [often] have no electricity within the adult critical care unit,” she said.
The Eastern Cape health department said it had been putting measures in place to improve maternal and reproductive health services in underserved areas. It said it would train healthcare personnel to “treat patients better” and is considering an integrated electronic system to keep patient records.
The commission’s chief executive, Dennis Matotoka, said those who suffered under the strained facilities in the province need justice.
“It is disheartening that during Women’s Month, we are reporting about women who are pregnant and sleeping on the floor until they get basic healthcare services. Something has to be done, and it is important that the department of health comes to the party and really ensures that justice is done.”
* Not her given name.
The Mail & Guardian
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