Abstract
The failure of numerous models to reduce maternal mortality ratios reveals the critical need to prioritise the improvement of maternal care standards. This study explored the contributory factors to caesarean section-related maternal death in the City of Tshwane, Gauteng province. A qualitative, descriptive, case study design was used, and the study was conducted at Dr George Mukhari Academic Tertiary Hospital in Tshwane.
Purposive sampling was used to select 15 maternal death files from a population of women who died between 2019 and 2023 following a caesarean section. An obstetrician assisted in analysing these files retrospectively using a puerperal monitoring tool for high-risk mothers. The researcher used qualitative coding analysis and identified key themes.
The analysis revealed that maternal deaths following caesarean section were largely preventable and reflected cumulative failures across the continuum of maternity care. Key recommendations include strengthening midwifery-led antenatal surveillance, postoperative monitoring, timely referral, and health system responsiveness. The outcomes of the study could help the hospital and the Department of Health to strengthen their postnatal care and provide ’guidance to midwives managing high-risk patients in the postnatal ward.