Karen Sliwa
University of Cape Town, South Africa; University of the Witwatersrand, Johannesburg, South Africa
Globally, cardiac disease is emerging as an important indirect cause of maternal death. Cardiac conditions can be preexisting, such as rheumatic heart disease (RHD) or congenital heart disease (CHD), and can be unmasked by the increased hemodynamic load in pregnancy, or can be caused by pregnancy, for example, in the case of hypertensive disorders or peripartum cardiomyopathy (PPCMO). Maternal mortality has been difficult to track over time at the national level, particularly in low- and middle-income countries (LMIC) such as in Africa. Incomplete data sets, inexperience of physicians in applying the classifications, and misclassification of maternal deaths to other causes in countries with complete vital registration are common problems [1]. Nevertheless, Table S1.1 highlights the more than tenfold higher maternal mortality rates in South Africa relative to higher income countries [1]. However, many cases remain unreported due to lack of linkage to the causality of the pregnancy. Maternal death is rarely reported beyond 6 weeks postpartum, and the ICD-10 classification defining late maternal mortality (6 weeks to 1 year) is often not applied. Consequently, death due to PPCMO, which often presents only 3 to 5 months postpartum and is characterized by fatal left ventricular (LV) dysfunction and heart failure (HF), remains unreported. The same applies to a range of maternal conditions, including other common hypertensive disorders in pregnancy and right heart failure (RHF) in complex CHD. Unfortunately, therefore, in the African context, a number of important maternal conditions are not adequately recognized or addressed to improve maternal heart health outcomes. Appropriately, this first section and chapter of The Heart of Africa examines key components of the spectrum and nature of heart disease from a maternal and “start of life” perspective.
Table S1.1 Comparison of maternal mortality per 100,000 live births worldwide.
Source: Kassenbaum et al., 2014 [1]. Reproduced with permission of Elsevier.
| Maternal Mortality Ratio (per 100,000 live births) | Number of Maternal Deaths | Annualized Rate of Change in Maternal Mortality Ratio (%) | |||||||
| 1990 | 2003 | 2013 | 1990 | 2003 | 2013 | 1990–2003 | 2003–2013 | 1990–2013 | |
| Worldwide | 283.2 258.6, 306.9 | 273.4 251.1, 296.6 | 209.1 186.3, 233.9 | 376,034 343,483, 407,574 | 361,706 332,230, 392,393 | 292,982 261,017, 327,792 | −0.3% −1.1, 0.6 | −2.7% −3.9, −1.5 | −1.3% −1.9, −0.8 |
| Developed countries | 24.5 23.0, 26.1 | 16.0 14.9, 17.0 | 12.1 10.4, 13.7 | 3827 3596, 4076 | 2341 2178, 2490 | 1811 1560, 2053 | −3.3% −3.8, −2.8 | −2.9% −4.2, −1.5 | −3.1% −3.7, −2.5 |
| Southern Africa | 150.8 115.9, 182.6 | 490.4 367.8, 626.1 | 279.8 202.6, 381.5 | 2455 1886, 2973 | 8406 6305, 10 733 | 4898 3547, 6679 | 9.1% 6.5, 11.8 | −5.6% −8.1, −3.0 | 2.7% 1.2, 4.4 |
| South Africa | 134.0 93.3, 175.2 | 341.8 227.8, 481.0 | 174.1 96.3, 274.9 | 1403 977, 1835 | 3739 2492, 5262 | 1925 1065, 3041 | 7.2% 3.3, 11.1 | −6.9% −11.1, −2.7 | 1.0% −1.6, 3.8 |
Each of the studies surveyed in Section 1 were situated in South Africa; beginning in Cape Town, the section subsequently shifts to Soweto, which will become prominent as a primary landscape of this book. In order to set the studies in context, a brief overview of South Africa in general and Cape Town and Soweto in particular is now provided. South Africa, located at the southern tip of the African continent, has a population of 53,675,563, almost half of whom are aged below 25 [2]. Approximately 80% of the population is of African ancestry; the remainder are white (8.4%), of mixed ancestry (8.8%), or Indian/Asian (2.5%) [2]. Average life expectancy in South Africa is 60.8 years for men and 63.9 for women. In 2015 the infant mortality rate was reported as 33 deaths per 1,000 live births [2]. Around 64% of the population is urbanized [3], and this is growing at an annual rate of 1.59% [2]. Although the literacy rate is at 94% [4], 24.9% of the total population are unemployed [5]. HIV/AIDs is the leading cause of mortality in South Africa, followed by stroke, type 2 diabetes, and ischemic heart disease (IHD) [6].
Cape Town is the second most populous city in South Africa, with around 3.7 million inhabitants [7]. A combined 80% of the population describe themselves as of African or mixed ancestry, with 15.7% being white and 1.4% Indian/Asian [8]. The majority of the population (almost 70%) is aged between 15 and 64 years, with around a quarter below the age of 15. In 2015 nearly 36% of households were living below the poverty line, with an unemployment rate of 23.9% [9].
The South Western Townships, also known as Soweto, is an urban area that forms part of Johannesburg, Gauteng. With a population officially estimated to be around 1 million people (some unofficial estimates are double and even triple this amount), 99% of Soweto’s inhabitants are of African ancestry [10]. All 11 of South Africa’s official languages are spoken in Soweto, with isiZulu, Sesotho, and Setswana being the most prominent. With a historically high unemployment rate, Soweto has a mixed (but predominantly low) income profile and is known for its “matchbox” houses in some areas and its upmarket, expensive properties in others [11]. Soweto is serviced by the world-renowned Chris Hani Baragwanath Hospital. Unofficially labeled the largest hospital in the world (for beds) at one time, it remains the largest hospital in South Africa, with >3,000 beds and >6,500 staff members [12].