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BACKGROUND: Reproductive health outcomes are a measure of maternal and neonatal health. South Africa’s state of maternal health is of particular concern because of the two Millennium Development Goals (MDGs) targets for monitoring maternal health, namely MDG 5a, to reduce the maternal mortality rate by three-quarters, and MDG 5b, to achieve universal access to reproductive health by 2015. Maternal mortality ratio and universal access to reproductive health receive unequal responsiveness from government. Monitoring the maternal mortality ratio has received favourable attention compared to ensuring universal access to reproductive health, hence the limited published research findings on the latter. OBJECTIVES: The purpose of this article is to report on the insights from reproductive health experts and verbal autopsies on the determinants of poor reproductive health outcomes. METHOD: Individual interviews with a purposively selected sample of six reproductive health experts were conducted, augmented by verbal autopsies of 12 next of kin of women and newborn babies who died within the previous 2 years period of the study. Burnard’s (1995) approach of content analysis was used to analyse the data. RESULTS: The findings revealed lack of empowerment, inaccessible reproductive health services and separation of patients living with human immune deficiency virus and those patients diagnosed with acquired immune deficiency syndrome. CONCLUSION: To meet the reproductive health needs, especially of the rural population, urgent attention is needed to reduce their vulnerability to the risks of poor reproductive outcomes.
A qualitative approach was used in this study. An explorative descriptive design was found to be most appropriate as the study aimed at exploring and describing the views of experts and the verbal autopsies of the next of kin of the mothers and neonates who died because of birth-related circumstances. This study was part of a larger study that looked at the overall health needs of the socially excluded, the deprived and the vulnerable women by exploring factors that influence maternal and child health (M&CH) outcomes. The study was conducted in two of the nine provinces of South Africa, namely Gauteng and KwaZulu-Natal (KZN). The health experts are located in Gauteng province where the National Department of Health is based. Gauteng province is the one of the nine provinces of South Africa and is the smallest of the nine provinces accounting for only 1.5% of the land area (Statistics South Africa 2012). For the purpose of this study, experts referred to people employed in the Department of Health with a higher qualification in reproductive health or with over 5 years of experience in the area of reproductive health and employed as such in the department. The experts also had responsibility in policy development and in overseeing its implementation. However, Gauteng province is highly urbanised and has Pretoria as its administrative capital. The South African health headquarters are also based in Pretoria, and hence all the experts were found in Gauteng province. The next of kin of the women and neonates who had died in the last 2 years because of birth-related circumstances lived in the rural villages of KZN. KwaZulu-Natal is the second most populous province in South Africa (Statistics SA 2012). The inhabitants of KZN who live in rural areas live below the poverty datum line on less than US$2 a day (Statistics SA 2012). KwaZulu-Natal province has been organised into 11 districts, among which is iLembe, a district chosen as a study site. Of all the districts, iLembe has been most affected by the HIV and AIDS epidemic, with the HIV prevalence rate of 45.9% among the antenatal care women in 2013 (South African Department of Health 2013). iLembe has also been classified as one of the districts that are socially deprived (Boerma 2014). Purposive sampling was used to select six experts in the area of reproductive health in South Africa and 12 next of kin of women and the neonates who had died recently (in the last 2 years) as a result of birth-related circumstances. Six reproductive health experts were recruited through the office of the chief director for women’s affairs. The inclusion criterion for reproductive health experts was that (1) they should have had training in the area of reproductive health, (2) they had worked in the area for 1 year or more and (3) they had knowledge of the health system of South Africa, and were responsible for policy development and overseeing its implementation. The next of kin were recruited through the assistance of the provisional department of health in KZN who gave the researchers registers to go through and identify would-be participants. Participants were later contacted by telephone and arrangements made for an initial visit; those who agreed to participate were explained the study, its objectives and how it will benefit participants in the end. This explanation was then followed by signing of the consent form or placing a thumb for those who did not know how to read and write. The inclusion criteria for next of kin of women who died in birth-related circumstances were that they should be: (1) husband, boyfriend, mother or sister of a woman of reproductive age who had died in the last 2 years of the time of study. (2) The woman had died while pregnant, giving birth or in the postnatal period, both within and outside public health institutions. (3) The next of kin had been living with the woman in the rural areas of KZN. For the neonates, inclusion criteria were that (1) she or he should be the mother of a newborn who had died or a caregiver of a newborn who died following its mother’s death and (2) the newborn should have died in the last 2 years of the study. Individual interviews were conducted with experts in their offices as per arrangement made between the first author and the experts. Because of time variations, these interviews took place from January to March 2014. Interviews with significant others or next of kin of the women and children who died were conducted in their homes with prior arrangement of time and date. They also took place between January and March 2014. Individual interviews with reproductive experts all started with a similar statement: ‘Tell me your views about reproductive services in South Africa’. This statement was followed by different probes according to the response. Some of the probes were: ‘What can be done to improve the current status of reproductive services?’ ‘How is the implementation of reproductive services done?’ ‘As an expert in the area of reproductive health, who do you think is responsible for the status of the services?’ For the next of kin, the general statement was also used as: ‘Tell me how you feel about the death of your baby? Mother? Wife etc.’ This question was also followed by probes depending on the answer. Some of the probes were: ‘Do you think her or his life could have been saved?’ ‘What is it that the nurses or doctors could have done?’ An adaptation of Burnard’s (1995) approach of data analysis was used in this study. Audiotaped interviews were transcribed word for word and coded in a series of stages by the first and second authors. Transcription and coding were made independent of each other. In accordance with Burnard’s approach, the tapes were listened to several times to allow the researchers to get deeper meanings of what was said by the participants. The third author was given four transcripts already performed by the two authors to check for consistency and she agreed with the interpretation of the first and second authors on different tapes. Transcription followed detailed written notes and themes were then developed and categorised.
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