News24 | This professor’s life’s work is to save mothers and babies from death during childbirth

Over a long and distinguished career, Professor Susan Fawcus has become known for her work trying to reduce the deaths of mothers and babies in South Africa. In her home in Cape Town, the soft-spoken champion for health equity chats to Spotlight about her journey as a researcher, doctor, and obstetrician, and shares her fears of rising maternal mortality in an age of austerity.

From Cape Town maternity wards to rural obstetric interventions and policy task rooms at the national Department of Health, Professor Susan Fawcus has played a key role in shaping South Africa’s response to the preventable tragedy of mothers dying while giving birth.

Seated at a table in her Plumstead home, the former head of obstetric services at Cape Town’s Mowbray Maternity Hospital from 1996 to 2018, reveals the harsh reality of maternal deaths in the country, using figures from Saving Mothers reports.

The reports, which Fawcus edited as a member of the National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD), note that in 2019, maternal deaths fell below 100 per 100 000 live births for the first time, reaching 98.8, but in 2021 it spiked to 148 as Covid-19 disrupted services.

Fawcus offers two reasons for the rise in maternal deaths during the Covid-19 pandemic.

“One, there were a lot of women who died from Covid pneumonia, usually in the later stages of pregnancy. So, that was probably the biggest reason,” she says. “And then the second reason was the effect on health services: emergency ambulances were being used for COVID, staff were off because they had Covid, or they were in quarantine.”

Behind each data point is a family ruptured by tragedy, Fawcus stresses. During the interview, her speech is matter-of-fact as she cites figures, her tone soft-spoken and measured. But it is apparent that this stoic facade belies a deep passion for the plight of mothers suffering and dying preventable deaths during childbirth.

The latest Saving Mothers report recorded 987 deaths, putting South Africa’s maternal mortality ratio at 111.7 per 100 000 in 2023 – in other words, not yet back to pre-Covid-19 levels. While there has clearly been some recovery after Covid-19, Fawcus is concerned that the numbers may be “flat-lining” at current levels.

There is substantial differences between provinces. Compared to 2022, the maternal mortality ratio in 2023 increased by more than 10 maternal deaths per 100 000 live births in the Eastern Cape, Free State, North West, and Northern Cape. The ratio stayed about the same in KwaZulu-Natal, Limpopo, Mpumalanga and Western Cape, and dropped in Gauteng.

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The latest report also states that non-pregnancy-related infections and medical and surgical conditions remain the most common causes of maternal death. This is closely followed by hypertension and obstetric haemorrhage (excessive bleeding).

And there are other concerning signs. According to the latest District Health Barometer, fewer women in South Africa are accessing care during their pregnancies.

At a national level, the percentage of women attending antenatal visits was at 69.4% in 2023/2024, a seven-percentage-point decrease from the 76.4% the previous year. Fifty out of 52 districts showed a decline in the last year. The authors of the relevant chapter in the District Health Barometer write that the decline “may in part be due to budget constraints in more recent years that may have negatively impacted on the accessibility of services”.

Global picture: 700 childbirth deaths a day

In April, the World Health Organisation (WHO) reported that most maternal deaths are preventable given that healthcare solutions to prevent or manage complications are well known. For example, it states that excessive bleeding after childbirth can kill a healthy woman within hours if she is unattended, and that injecting oxytocics (medication that stimulate uterine contractions) immediately after childbirth could effectively reduce such risk of bleeding.

The WHO report adds that a maternal death occurred almost every 2 minutes in 2023, meaning that every day over 700 women died from preventable causes related to pregnancy and childbirth, with 70% of these deaths having occurred in Sub-Saharan Africa.

Maternal lives threatened following budget cuts and Pepfar collapse

Fawcus says she doubts South Africa will reach the Sustainable Development Goal (SDG) to reduce the global maternal mortality ratio to less than 70 per 100 000 live births by 2030. The global maternal mortality ratio was 197 per 100 000 live births in 2023, substantially higher than the most recent number of 111.7 in South Africa. To reach the SDG goal, countries would require an annual rate of reduction of almost 15% - a rate that has rarely been achieved at the national level, according to the WHO. According to our back-of-the-envelope calculations, the rate in South Africa would have to decline by well over 6% per year to meet the target.

But whether such reductions will be possible in the current context is questionable. Fawcus says she is concerned about South Africa’s health budget cuts, compounded by the collapse of the United States President’s Emergency Plan for AIDS Relief (Pepfar). Among others, Pepfar funded several large NGOs that provided services to people in South Africa, including some programmes that focused on young women.

She says:

The withdrawal of funding from the United States is curbing some primary healthcare programmes, which Fawcus says successfully helped reduce childbirth deaths. “It will be important to see what happens over the next few years with maternal mortality, because it did drop due to very effective antiretroviral therapy for pregnant women living with HIV, and lots of other initiatives, including around high blood pressure and postpartum haemorrhage,” she says.

Early roots: Kenya, England and Zimbabwe

Following her early childhood in Kenya, Fawcus grew up in England where she completed a Master of Arts degree in physiological sciences at Oxford University followed by medical school at the University of London.

Thinking back to her formative years in England’s Midlands, becoming a healthcare professional always seemed an obvious career choice.

“I remember once walking to school and the guy sweeping the road stopped me because he had a thorn in his finger and it was all sort of infected. And I spent quite a lot of time helping him with his finger. And somehow it made me feel that I liked helping people with health problems,” Fawcus recalls.

An awareness of women’s unique health challenges would soon follow. “It was during my study years that I began to see that there was a real need in women’s health, that women’s health has been quite neglected,” she says.

In 1980, she moved to Zimbabwe with her now-deceased, Professor David Sanders – a well-known academic and healthcare activist who founded the School of Public Health at the University of the Western Cape.

Fawcus was training as a junior doctor at Harare Central Hospital at a time when established thinking about maternal health was being challenged. An article published in the Lancet medical journal in 1985 highlighted systemic failures that allowed healthy women to die during pregnancy and birth, particularly in low- and middle-income countries.

The authors wrote:

Correcting this would come to drive Fawcus’ working life.

She recalls her formative years in Harare: “It was a very busy hospital and so I became a very competent hands-on clinical doctor, surgery and all that.”

She says partaking in a pioneering study run by the Swedish Agency for Research and Collaboration along with the University of Zimbabwe opened her eyes.

“It was the first time anyone had really done a community-based survey of maternal mortality, because up to then, all the statistics had been based in facilities,” she says. “So we identified all these women in rural areas who died in childbirth, many of whom never got to a hospital. And for each one, field workers went to interview the family about what had happened.

“It was one of my biggest learning experiences because I saw that while obviously what you do in a hospital makes a huge difference, a lot of it is about what happens before you even get to a hospital and relates to poverty and a lack of transport. It inspired me to work better as a doctor for women and as an obstetrician. I just saw the bigger picture.”

Democratic South Africa’s maternal health transformation

A decade later, Fawcus moved to Durban, then to Cape Town, where she was “invited” to participate in South Africa’s maternal health transformation led by the country’s first democratically elected health minister, Nkosazana Dlamini-Zuma.

Fawcus recalls contributing to the Choice on Termination of Pregnancy Act promulgated in 1997 - critical legislation that allow women access to abortion services.

In 1998, Dlamini-Zuma set up the NCCEMD as an audit system, which, to this day, reviews every reported maternal death in South Africa.

Fawcus has served on the NCCEMD investigating deaths and drafting national protocol recommendations on issues like haemorrhage management and caesarean section care. She has served as the committee’s deputy chairperson and as editor of its annual and three-yearly Saving Mothers reports. “I still serve [on the NCCEMD], but now I’m sort of handing over to other people … and mentoring them,” she says.

About her time leading at Mowbray Maternity Hospital, which sees some 1 000 births a month, she says: “It made me really passionate about working in the public sector. You know, so many people get very impatient about the public sector – and it’s true, things take a while. But what if we could devote our energy into making it function better?” (Spotlight previously featured Mowbray Maternity in its Hospital Histories’ series.)

She highlights the success of Cape Town’s public healthcare referral system. “The Cape Metro has a very good system of maternity care, which I think is why it’s results are quite a lot better than some other places. The approach here, really from about the 1970s, has been to develop these midwife obstetric units near where people live, for example in Gugulethu, Mitchells Plain and Retreat, run by midwives. Many women give birth at these units. If they develop complications or have medical problems, they will come through to Mowbray Maternity, and the very, very sick women would end up at the emergency wards at Groote Schuur Hospital”.

A mother of three babies delivered by midwives

In her sitting room, family portraits are displayed on a wooden cabinet. Fawcus herself is a mother of two sons and a daughter delivered by midwives. “I think caesarean section is a lifesaving procedure; it can be for the mother and the baby. But there are far too many unnecessary ones in the private sector,” she says.

At 72, Fawcus is still involved with the University of Cape Town’s Department of Obstetrics and Gynaecology where she is a senior scholar and professor emeritus. She continues to do research, now on pre-eclampsia, a pregnancy complication marked by the sudden onset of high blood pressure. Fawcus also serves on the steering committee of the South African Obstetric Justice Coalition, which is linked to Embrace - a civil society group focused on listening to women and addressing any experiences of disrespect and unkindness during childbirth.

As we wrap up our interview, Fawcus reflects on her career in her typical understated manner: “It’s been quite a long journey looking at maternal mortality in South Africa and all the trends. And I’m still continuing. I’m still involved. I am definitely not ready to ‘not do anything’ yet.”

This article was first published by Spotlight – health journalism in the public interest. Sign up to the Spotlight newsletter.