BLOEMFONTEIN, SOUTH AFRICA – MARCH 11: (SOUTH AFRICA) A newborn baby at the Kangaroo Mother Care Centre at Pelonomi Hospital in Bloemfontein, South Africa. On March 11, 2014, the Kangaroo Mother Care Centre helps women across the Free State province who give birth prematurely to care for their babies until they are old enough to give birth. Kangaroo care is a method of care given to premature babies in which the infant is held skin-to-skin by an adult. The concept was first developed to care for premature babies in areas where incubators are not available or reliable. (Photo: Conrad Bornman/Gallo Images/Getty Images)
Nurses at Livingstone tertiary hospital in Gqebela in the Eastern Cape say hospitals are difficult and stressful places to work, citing corruption and poor governance as key factors in medicine shortages and poor maintenance of infrastructure.
“We've been struggling since the beginning of the year just with basic medical equipment. I'm talking about needles. I'm talking about syringes. I'm talking about IV bags and drips. Not to mention medicines and situations where we have to turn patients away because we don't have the medicine or the equipment to carry out certain procedures,” said Zanele Ndoda.
She said staff have had to improvise, as a lack of resources such as incubators means premature babies have to be kept in boxes.
“This is just a routine, we have to improvise, if we report that something is missing or we don’t know this procedure. [the necessary tools]you are told you are a nurse and you need to improvise.”
The hospital's maternity unit was one of six health facilities inspected by the Gender Equality Commission, the others being Cecilia Makiwane Hospital in Mdantsane, Frere Hospital in East London, Bhisho Hospital, Dora Nginza Provincial Hospital in Zwide County, Gqebela and St Elizabeth Mission Hospital in Lusikisiki.
The report, released last week, found that despite government efforts to promote gender equality and women's health, some provinces, particularly the Eastern Cape, struggle to provide adequate and quality health services to women.
“The Eastern Cape is particularly affected by rising maternal and neonatal mortality rates,” the report said.
The Eastern Cape has 775 primary health care facilities, of which 733 are clinics and 42 are community health centres. It also has 90 hospitals.
According to the District Health Information System, the maternal mortality rate in health facilities in the province increased from 106.1 in 2019 to 108.2 in 2020. An increase was also seen in the Northern Cape, while all other provinces reported a decrease in maternal mortality during the reporting period.
Cecilia Makiwane Hospital, which together with Frere Hospital has a population of 267,000, recorded 17 maternal deaths per Year-round Problem Specified Issue (PPIP) and 15 per District Health Information System (DHIS) in 2020-2021. This decreased to 11 maternal deaths per PPIP and eight maternal deaths per DHIS in 2021-2022, before increasing to 13 maternal deaths per PPIP and 12 maternal deaths per DHIS in 2022-2023.
The committee noted that the majority of deaths in 2020 and 2021 were due to the COVID-19 pandemic.
Neonatal deaths were cited as a concern: from April 2020 to March 2021, the mortality rate was 14.3%, the following year it was 11%, but is expected to rise again to 13.9% from April 2022 to March 2023.
“These deaths were due to a variety of causes, including maternal hypertension, spontaneous preterm birth, infection and neonatal unit overcrowding,” the report said.
However, the committee commended Cecilia Makiwane Hospital for cleanliness, maintenance and proper ventilation.
“It is a state-of-the-art facility in terms of infrastructure and good administration and it would have been nice if similar initiatives had been implemented in other hospitals,” said Tsietsi Shuping, the commission's acting director of legal services.
The report said overcrowding was widespread in six health facilities – Livingstone, Cecilia Makiwane, Frere, Bhisho, Dora Nginza and St Elizabeth.
“While overcrowding is not uncommon, deaths from infectious diseases attributable to overcrowding should not be frequent,” the report said.
The report said the 220-bed Dora Nginza district hospital was so overcrowded that patients had to sleep on benches or share beds.
“Further investigations established dire conditions within the maternity ward, with cases of postnatal patients being evacuated due to a lack of beds and some being forced to makeshift sleep on the floor or benches.”
Additionally, early neonatal mortality and neonatal mortality rates in facilities increased consistently from 2020 to 2023, despite the facilities being “well maintained” in terms of buildings, flooring, ventilation and general hygiene.
Bhisho Hospital has 205 beds for a district population of 100,000. Regarding the quality of the facilities, Shuping said, “There was noticeable mould in the bathrooms and overall cleanliness was an issue, exacerbated by a lack of rotation of maintenance staff, highlighting the need for improved facility management.”
“We realised that the isolation rooms' proximity to the neonatal wards posed a risk of infection. Infection units and wards should not be located near wards serving vulnerable people, children and new mothers.”
The facilities also suffered from staff shortages and limited resources, with a lack of beds resulting in long wait times and hindering medical services, and patients sometimes had to bring their own sheets, putting them at risk of infection, Shuping said.
Although facilities met certain standards, they were inadequate in providing health and reproductive services to women.
According to the report, one maternal death due to lower respiratory tract infection was recorded at Meisho Hospital in fiscal years 2021 and 2022. Two more maternal deaths were reported in the following period.
“The occurrence of deaths from various causes highlights the importance of comprehensive health care and the need for appropriate medical interventions tailored to specific circumstances to prevent deaths,” the report said.
An increase in neonatal deaths occurred between 2020 and 2023, with a total of 72 early neonatal deaths and 10 late neonatal deaths reported.
Births among adolescents aged 10 to 19 also contribute to higher maternal and neonatal mortality rates, according to the report.
This was common at St. Elizabeth Hospital.
“The high birth rate among patients aged 10 to 14 is alarming. St. Elizabeths Hospital ranks fifth nationally and first in the state for sexual assault and rape cases, and it is concerning that despite these high figures, there is no indication that the hospital has taken steps to report statutory rape cases to authorities,” the report said.
A total of 3,669 births were reported for children aged 10 to 14 years from 2020 to 2023. The total number of stillbirths during the same period was 306, and 151 deaths of infants up to six days old.
Frere Hospital was found to have “numerous deficiencies”, including poor infrastructure, poor ventilation, hygiene issues and inadequate waste disposal.
The hospital served approximately 3 million patients and was considered a “prestigious medical institution,” but its conditions were substandard.
“From what we observed, the hospital's infrastructure was poorly maintained – the roof was leaking, there was mould, the paint was peeling and cleanliness was poor,” Shuping said.
“The underground tunnel leading to the maternity ward posed hazards, including exposed electrical wires. [heightening] There is also a risk of fire or electric shock.”
“While passing by the air conditioner [standard]We noticed inconsistencies in terms of window function and shielding, impeding ventilation and leading to discomfort and potential infection.”
The maternal and child care unit at Frere Hospital was also overcrowded and there were long waiting times for women seeking abortions, often forcing them to resort to unsafe backdoor abortions.
The number of maternal deaths fell to 16 in 2022 and 2023, down from 20 in 2021 and 2022. The committee said these deaths were generally due to pre-existing maternal diseases such as respiratory diseases, congenital heart disease and blood disorders. Other causes of death were AIDS and ectopic pregnancy.
There was wide variation in early institutional neonatal mortality.
It rose to 29.4% in June 2020 but fell to zero by September 2022, according to the report.
On average, early neonatal mortality was lower than late neonatal mortality from April 2020 to March 2023. These deaths were primarily attributable to conditions related to prematurity, although variations indicate changes in healthcare practices and resources.
“The variation in rates over time highlights the need for ongoing monitoring and evaluation of health services to identify areas for improvement and implement targeted interventions,” the report said.
The commission noted that health facilities in the Eastern Cape generally needed to improve management and governance and that problems were not caused by a lack of resources but rather due to resources not being used correctly.
Ndouda, a nurse at Livingstone Hospital, said that in addition to the electrical system failure, the safety of staff and patients also had to be addressed as a top priority.
“We use a lot of electricity because we have a lot of machines, ventilators, monitors, everything we need to keep patients alive. And sometimes the wall sockets don't work. [often] “There's no electricity in the adult intensive care unit,” she said.
The Eastern Cape health department said it was taking steps to improve maternal, child and reproductive health services in underserved areas. The department said it was training health workers to “better treat patients” and was looking at an integrated electronic system for keeping patient records.
The commission's chief executive, Dennis Matotoka, said people who have suffered under strained facilities in the state want justice.
“It is unfortunate that during Women's Month we report on women who are pregnant and sleeping on the floor without access to basic health services. Something must be done. It is important that the Ministry of Health step in to ensure that justice is truly delivered.”
*Not her real name.
