South Africa is a middle-income country and the richest in sub-Saharan Africa. It spends more on health per person than any other on the continent, and it provides this healthcare free, including services for pregnant mothers. And yet, the maternal mortality rate - the proportion of South African women who die in childbirth or from complications of pregnancy and birth - has quadrupled in just over a decade. How is this startling and counter-intuitive trend to be explained?

It is possible that some part of the increase is attributable to more accurate reporting. The most recent government statistics show the rate rising from 150 to 625 maternal deaths per thousand live births between 1998 and 2007. While this coincides with a period in which the collection of health data in South Africa has improved, the public-health experts are wary of overstating the contribution of better data and generally agree that the trend in maternal deaths is up, and substantially so.

The most commonly cited reason is the impact of HIV and Aids. South Africa has more people living with HIV than any other country in the world, an estimated 5.7 million South Africans (18% of the population). South Africa’s past failure to address HIV and Aids effectively has contributed to soaring infection rates, alongside the country’s horrendous levels of sexual violence. The opposition of previous political leaders to the use of anti-retroviral drugs, including for the prevention of mother-to-child HIV transmission, was a substantial contributing factor.

Data from the South African National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD) suggest that 44% of maternal deaths could be attributed to HIV and Aids (between 2005 and 2007) and that the mortality rate for HIV-positive women was nearly ten times as high as for HIV-negative women.

But while critically important, the impact of HIV and Aids on maternal deaths should be viewed in a broader context. Similarly, the national and global debate on maternal health needs to move beyond its excessive focus on overall levels of health spending, and consider the range of factors that lead to poor health outcomes for pregnant women and new mothers. New research by Human Rights Watch - conducted in South Africa’s Eastern Cape province - suggests that poor quality and unresponsive care for mothers and health systems devoid of effective accountability to patients or the public are particularly important in shaping (and worsening) maternal-health outcomes.

A pattern of abuse
In the course of our research, women told Human Rights Watch that they were physically and verbally abused, including pinching, slapping and rough handling during labour. They also described treatment delays; nurses who ignored calls for help; and health facilities that failed to deal appropriately with pregnancy or childbirth-related problems. Women were also left unattended for long periods after delivery, discharged too soon or sent home without pain medication or antibiotics, sometimes after Caesarean births, and refused admission, even when they were clearly in labour.

Women also described widespread verbal abuse. They said that when they sought care for pregnancy, nurses taunted them about enjoying sex or berated them for getting pregnant knowing they were HIV-positive, or told them they did not deserve care because they were migrants. Others said that nurses ridiculed women when they said they were having labour pains or pleaded for assistance. Some also noted that hospital workers demanded bribes or gifts.

These testimonies reveal shocking disrespect and abuse of a large number of very vulnerable women in Eastern Cape. Their stories may also help explain the high and worsening levels of maternal mortality in Eastern Cape and elsewhere in South Africa. Ill-treatment drives women away from seeking care. Abuses also lead to delays in diagnosis and treatment, which feeds through into increased morbidity and mortality rates.

A comprehensive response
It is first and foremost for the elected representatives of the Eastern Cape and for South Africa’s national government to address these abuses. At the policy level, South Africa is now saying many of the right things, including a raft of sexual and reproductive health-related laws and policies and a constitutional guarantee of the right to health. But there is clearly a very large gap between law and stated policy and actual practice, as it is experienced by ordinary South African women.

The challenge for South Africa is to overhaul the current administration of many of its health facilities and to make them much more accountable and responsive to mothers and to other patients. This should include proper complaint systems, so that mothers feel empowered to raise their concerns, and health workers and those who run health facilities can actively solicit information from patients to improve the quality of care.

A far-reaching shift is needed if there is to be a real prospect of South Africa meeting its international commitment to reduce maternal mortality by three-quarters between 1990 (the base year) and 2015 (the target date). There are lessons here for donors too, like the UK’s department for international development (DfID), which plans to spend £33 million ($53 million) over the next five years on reproductive, maternal and newborn health in South Africa.

If this is going to have real and lasting impact, DfID will need to focus more heavily on the quality of maternal health services, the rights and treatment of women during pregnancy and in labour, and the responsiveness and accountability of health systems to women, especially the poorest and most marginalised women. Without this more comprehensive approach, on the part of national governments and international donors, women will continue to die unnecessarily and tragically, not just in South Africa but in many other countries around the world.

David Mepham is UK director of Human Rights Watch