South Africa has achieved near universal access to health services for pregnant women and their children, but maternal and infant mortality rates have continued to rise making the chances of reaching the Millennium Development Goals (MDGs) on maternal and child health increasingly remote.
A new national study, Health of our Children in South Africa, confirms that HIV/AIDS is the biggest cause of maternal deaths, and accounts for 35 percent of deaths in children under five. But the study reveals that poor quality health care, low immunisation rates and misguided infant feeding practices also contribute to the poor health of pregnant women and children in South Africa.
The study, released on 13 May, draws on data in a national HIV, behaviour and health survey conducted in 2008 by the Human Sciences Research Council (HSRC) and several partner organisations, including the United Nations Children's Fund (UNICEF) and the Centre for AIDS Development, Research and Evaluation (CADRE).
Similar studies were carried out in 2002 and 2005, but this is the first with data on children younger than two. Researchers surveyed 8,066 children under the age of 18 to determine their HIV and general health status, what HIV risk factors they had been exposed to, and their access to AIDS information.
Although the overwhelming majority of South African children were HIV negative and in good health, for the nearly 3 percent of children surveyed who were HIV-positive, "mortality during the first five years is high", and those living with HIV were three times more likely to be hospitalised than other children.
Sexual transmission was the main cause of HIV infection in children over the age of 12 - one in seven girls, and one in 10 boys aged between 12 and 14 had already had sex. More than a quarter of girls aged 12 to 18 had had sex with partners at least five years older, putting them at an increased risk of HIV. However, 92 percent of young men and 84 percent of young women reported that they had used condoms the last time they had sex.
Most of the 3.3 percent of children younger than four years who were HIV-positive had been infected by their mothers. A slightly lower HIV prevalence of 2.1 percent among infants under the age of 2 suggested that South Africa's prevention of mother-to-child HIV transmission (PMTCT) programme was having an impact. Of the 97 percent of pregnant women who accessed antenatal care, 95 percent said they were offered an HIV test.
Poor quality care
Although most mothers reported using the available healthcare services for their children, the study found that the quality of services was often inadequate.
Dr Khangelani Zuma of the HSRC, a study investigator, described the low rates of immunization for preventable childhood illnesses like measles, diphtheria and polio as "missed opportunities", and suggested that the policies and guidelines governing immunisation and other maternal and child health efforts were of little use without proper oversight to ensure implementation.
South Africa's new national treatment guidelines include antiretroviral (ARV) treatment for all HIV-positive infants under the age of one year, and for pregnant HIV-positive women with a CD4 count (which measures immune system strength) of 350 or less, which could significantly reduce maternal and infant mortality rates if fully implemented.
"Based on our results, I'm concerned about implementation unless bigger efforts are put in place to make sure guidelines are followed," Zuma told IRIN/PlusNews. "The new guidelines could see an improvement if more is invested in an accreditation system to monitor the quality of care in our health facilities, and to hold health managers accountable." The study authors include such a system in their recommendations.
Mixed feeding raises HIV risk
Other recommendations address the finding that only a quarter of South African women surveyed exclusively breastfed their babies during their first six months; most relied on mixed feeding (a combination of breast milk and formula), which has been associated with a high risk of mother-to-child transmission of HIV in the first three months of life.
The authors propose revising the current feeding policies to take into account the 2009 World Health Organization guidelines, which recommend that HIV-positive women begin ARV treatment early in pregnancy and continue until they stop breastfeeding.
Zuma said better health outcomes for pregnant women and children would require addressing resource shortfalls, such as the inadequate supply of ARVs at some public health facilities, and staff shortages at others. "What we need to do is invest more in the overhaul of our health system."