Maternal mortality in 18th Century Cape and in 2018 South Africa: poor access to healthcare, over-medicalisation or both?

Anja Smith | May 2018

We celebrate pregnancy with baby showers and the expectation of a long and happy life with the new baby, who will eventually grow up into a difficult teenager.

While pregnant mothers and their partners may be the aware of the risks associated with pregnancy and childbirth, the likelihood of things going extremely wrong is a quite small one. This wasn’t always the case.

I am currently working with colleagues¹  at the Economics Department of Stellenbosch University to explore patterns in maternal deaths among settler women in the 18^th century Cape. We consider maternal deaths during the period 1700-1773, but are likely to expand our analysis as more data becomes available.

As you probably expect, maternal mortality rates were incredibly high during this period. Surprisingly, we find that richer women and, after controlling for wealth, Huguenot women, were more likely to die from childbirth. This unexpected finding has sent us down the proverbial historical rabbit hole to find answers for these patterns. In doing so, linking our historical explorations to current-day considerations on maternal health has been unavoidable. Contemporary medical discussions highlight the global issue of both over-medicalisation and under-medicalisation in maternal health, with catch phrases such as “too little too late, and too much too soon”² being coined. Debates are raging on what constitutes appropriate maternal care.

Historical causes of maternal death

After digging into the literature, we now have a much better idea of the broad causes of maternal mortality up to the 1930s and how access to “proper” care made little difference in these patterns (in fact, what is now perceived as “proper” care may have caused your death earlier than necessary).

Puerperal fever, infection of the birth canal, was the main cause of death up to the 1930s³. At this time, anti-bacterial knowledge and practices started to be widely rolled out at hospitals and the first antibiotics were developed. Up to that point, death had been indiscriminate about which mothers to take. Rich and poor mothers were equally like to die due to childbirth related causes. Nutrition (and therefore wealth) made little difference to maternal mortality. In fact, in some countries, rich mothers were more likely to die than poor ones.

Historical data on British maternal mortality shows that richer groups experienced much higher maternal mortality compared to poorer groups⁴. This may have been due to a preference for doctors, rather than midwives, to attend to the labour process of richer women. Since doctors had greater exposure to potentially life-threatening bacteria (because they also dealt with the sick) compared to midwives (who only dealt with healthy mothers), being attended to by a doctor at birth was associated with a greater likelihood of bacterial exposure. Doctors could carry the very cause of maternal death into the birth room.

In contrast, midwives may have been the safer and more appropriate option. It would not be far-fetched to conclude that already in 17^th/18^th century Britain, the first signs of a preference for over-medicalisation was playing out among richer groups.

Isolation from care on the Cape frontier

Death and birth data, including maternal deaths, of the settler population was recorded by the Master of the Orphan Chamber in Cape Town. For more data on who these women were, we match these records to the opgaafrollen, or tax roll information, kept by the Dutch East India Company (VOC) to calculate households’ tax burden. Our data covers the entire European settler population during this period.

The Huguenots lived on the early Cape Frontier in the outlying areas of then Drakenstein (now Paarl) and Franschhoek. They were more educated, and also wealthier, than the typical immigrant inhabitant of Cape Town was. We know they tended to live and socialise in isolated, small networks. They were also the group who experienced the highest maternal mortality. Apart from isolation brought on by their language (French compared to Dutch in the rest of the colony), they were geographically isolated. The few officially trained Dutch midwives (they received their training in the Netherlands) were based in Cape Town. We find no mention in the available records of either a doctor or a midwife attending at the birth of a Huguenot woman.

Unlike the case of historical Britain, it seems unlikely that the higher maternal mortality among Huguenot women as due to over-medicalisation. It is far more likely that social and geographical isolation meant limited access to skilled birth attendants.

What we find and the relevance to today: over- and under-medicalisation

Both the historical experiences around over-medicalisation and our findings about lack of access to healthcare on the Cape frontier raise an important parallel with discussions in the contemporary medical field. Many lower- and middle-income countries, and even poorer individuals and areas in rich(er) countries still struggle with limited access to quality healthcare (under-medicalisation). However, for many high-income countries, and richer individuals in those countries, over-medicalisation in pregnancy and childbirth has become a reality.

The lessons from the Cape Colony and the Huguenots living on the Cape frontier still have relevance today. Pregnant women, and women in labour, require timely access to appropriate and sufficient healthcare. For South Africa looking ahead towards National Health Insurance (NHI), this raises questions about who should provide care at childbirth (midwives, obstetricians, or teams of carers with an appropriate mix of skills, and then in what ratio/combination), what type of care or medical intervention/assistance should be provided and be encouraged (vaginal births or C-sections) and in what setting (clinics, maternity obstetric units, hospitals or even at home)?

The South African private health sector is struggling with both the outflux of obstetricians due to the high cost of medical liability insurance⁵ and its controversially high-C section rates (over-medicalisation?). The public health sector is still suffering from unnecessarily high maternal mortality rates. Despite great strides having been taken in expanding public healthcare access in the post-apartheid era, timely access to appropriate care is not always forthcoming (under-medicalisation). History, both international and South African, provide strong pointers for what is needed. Now we require leadership, vision and a strong will for implementing the necessary changes.

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¹ Dr Dieter von Fintel, Prof Ada Jansen and Dr Sophia du Plessis.

² Miller et al. 2016. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. Lancet. 388: 2176–92.

³ Loudoun, I. 2000. Maternal mortality in the past and its relevance to developing countries today. American Journal of Clinical Nutrition. 52 (2000a), 241S–246S.

⁴ Loudoun, I. 2000. Maternal mortality in the past and its relevance to developing countries today. American Journal of Clinical Nutrition. 52 (2000a), 241S–246S.

⁵ Taylor, B., van Waart, J., Ranchod, S. and Taylor, A. 2018. Medicolegal storm threatening maternal and child healthcare services. South African Medical Journal, 108(3), pp.149-150.