Funciones de los Empleados del CEYPSA

The work of Ayrton et al. (2009) is directly related to Southern Sudan, but it was conducted before the area became an independent country. Ayrton et al. (2009) used data from hospital

records to confirm the causes of deaths and categorised them by the age of the patient and the duration of their hospital stay.

The five direct major causes of maternal deaths are: haemorrhaging (bleeding), sepsis (infection), unsafe abortion, eclampsia, and prolonged (obstructed labour). Major indirect causes are anaemia, malaria, heart disease, and HIV/AIDs. Almost all of these life-threatening complications can be prevented or treated if women have access to high-quality and apposite healthcare during pregnancy, abortion, childbirth, and immediately afterwards.

2.2.2.1 Haemorrhaging

Obstetric haemorrhaging is the single, most significant, cause of maternal mortality globally, accounting for 25%–30% of all maternal deaths. Obstetric haemorrhaging causes 127,000 deaths yearly worldwide and is the leading cause of maternal mortality (WHO report, 2015; Haeri, 2012; Parata et al., 2014, Tort et al., 2015; Devi et al., 2015).

A haemorrhage is referred to as a blood loss of 500 ml or more during puerperium and a severe haemorrhaging as blood loss 1000 ml or more according to reports by RANZCOG (2011, 2014, 2015, 2016, 2017). The WHO defines haemorrhaging as blood loss of more than 500 ml in the first 24 hours after birth (Walfish et al., 2009).

Most deaths related to haemorrhaging occur during the first 24 hours after delivery. Most could be avoided using a prophylactic uterotonic during the third stage of labour, and through timely and appropriate management (WHO, 2012).

In Senegal and Mali, obstetric haemorrhaging is the leading cause of maternal death (Tort et al., 2015). In Asian countries including Japan, China, Hong Kong, Pakistan, Thailand, Indonesia, Saudi Arabia, Sri Lanka, and other developed countries, postpartum haemorrhaging is the most significant cause of maternal mortality (Duthie, 2014). In India, haemorrhaging is a major cause of maternal deaths (Devi et al., 2015), and in Bangladesh, haemorrhaging is also the leading cause of maternal mortality, accounting for around 31% of maternal deaths (Prata et al., 2014).

In the US, obstetric haemorrhaging is still the main cause of maternal deaths and around 54% to 93% of these deaths may have been preventable (Bingham and James, 2012). In Australia and New Zealand, postpartum haemorrhaging remain the main cause of both maternal mortality and morbidity. The prevention and treatment of haemorrhaging is a crucial step towards the achievement of the Millennium Development Goals (WHO, 2012) and the reduction of MMR.

2.2.2.2 Unsafe Abortions

Unsafe abortion remains a serious and continuing public health challenge for global maternal deaths and is associated with both short- and long-term morbidity in women (Auka et al., 2015; Khan, 2003).

Worldwide, 20 million illegal abortions occur each year. It is estimated that globally; unsafe abortions are responsible for about 68,000 deaths annually, accounting for 13% of total maternal mortality (Regmic et al., 2010; WHO, 2011, 2014; Auka et al., 2015).

According to Johnston et al. (2007) and the WHO (2004), the unsafe abortion mortality ratio is highest in Africa at 100 per 100,000 live births; in Asia it is 40 per 100,000 live births and 30 in Latin America and the Caribbean, whereas in developed countries it is as low as three. Abortion is illegal in South Sudan except when it is done to save a woman's life (Women on Waves, 2017). Gender-based violence is very common in South Sudan. Abortion is illegal even when a woman has been raped, and women are often discriminated against and blamed in such instances (Women on Waves, 2017).

2.2.2.3 Malaria as an indirect cause of MMR

About half of the world population is at risk of malaria and most cases occur in sub-Saharan Africa including South Sudan (Cornelio and Seriano, 2011; WHO, 2010), where 20% of childhood deaths result from this disease.

South Sudan is one of the highest malaria burdens in sub-Saharan Africa (Aimeek et al., 2016). Thus, it would be safe to conclude that the malaria, as an indirect cause, has a major role in high MMR in the country.

In 2008, there were 247 million worldwide cases of malaria and approximately one million deaths. Malaria is a major cause of prenatal anaemia and preventable low birth weight (Cornelio and Seriano, 2011; Attwood et al., 2012).

In 2010, around 219 million malaria cases and 660,000 deaths were reported globally (Chanda et al., 2014; WHO, 2014). The disease remains a main cause of maternal mortality, exacting its greatest toll in sub-Saharan Africa, where over 80% of cases and 90% of deaths occur (Pasquale et al., 2013; WHO, 2012, 2013, 2014; Chanda et al., 2014). Malaria is a major health problem in South Sudan. Around 95% of South Sudan is endemic for malaria and transmission is high throughout the year (Draebel et al., 2013). An estimated 2.3 million people are at risk of malaria across the whole country. The peak period of transmission is during the rainy season, mainly April to October (Cornelio and Seriano, 2011; MoH, Government of Southern Sudan, 2006). Moreover, the frequency and severity of malaria infections are greater during pregnancy and may cause severe anaemia, increasing the risk of maternal mortality.

A review of 20 researches from eight African countries, found that the prevalence of malaria infection in pregnancy ranged from around 10% to 65%, and estimated the median prevalence of maternal malaria infection in all pregnant women accounted for 27.8% (Draebel et al., 2013).

The prevalence of malaria is very high in South Sudan, accounting for around 30% of deaths of all malaria-related hospital admissions (MoH, 2009). Children under five and pregnant women are the most at risk from malaria. Charchuk, Houston, and Hawkes (2015) found that the prevalence of malaria is high amongst school-aged children and adolescents in the South. It is hypothesised that the high prevalence of malaria is due to the fertile grounds for mosquito breeding, low levels of intervention, and low levels of knowledge regarding the disease (Eyobo, et al., 2014). In the 2009 malaria indicator survey, it was found that only 34% of households own a mosquito net and only 41% of households know the correct treatment for malaria. It was also found that only 52% of children with malaria received treatment at a health

In South Sudan, especially during the rainy season, malaria is responsible for most admissions and is the leading cause of mortality in the Medical Department of Juba Teaching Hospital (JTH).