Selena Msiza sits stiffly on the edge of one of the brown and gold couches in the carefully decorated lounge of her home in Vlaklaagte No 1, a rural village in Mpumalanga. An empty smile is plastered across her face. But a faint frown appears and she shakes her head as she recalls the day her daughter died.
"I still can't believe that my child is really gone. She was only 23.
"Sometimes, it feels like my heart is going to stop beating just thinking about her," she says quietly.
About three months ago, her daughter Lindiwe died suddenly after giving birth to twins. Her mother and husband now take care of the two baby boys.
Msiza recalls the hot Sunday morning of her daughter's death. "I was cleaning Lindiwe's room so that she could relax when she came back from the hospital." She slowly looks away. "But I was deluding myself. She was not coming back."
The night before, about a week after she had given birth, Msiza and her son-in-law rushed Lindiwe to the KwaMhlanga Hospital in Mpumalanga's Nkangala district. She was struggling to breathe. When they arrived, they were told that there was no electricity and that they would have to come back later.
"By the time we got back home from the hospital, it was about three o'clock in the morning. We didn't sleep because Lindiwe's condition was getting worse," Msiza says, looking down at her hands. "Eventually, around 5am, I told my son-in-law to take her to a doctor in Bronkhorstspruit [about 50km away]."
But on the way to the doctor, Lindiwe's condition deteriorated and her husband took her back to KwaMhlanga, where she was eventually admitted.
"He left her at the hospital and planned to come back to see her during visiting hours later that morning but, just as he arrived home from the hospital, they called him to tell him she had died. He called me and said, 'Ma, they say she is gone'."
"But, how did she die, when I'd seen her five hours ago?" Msiza asks. "Her condition wasn't so bad that she should have died from it. She walked into the hospital on her own; we didn't have to carry her."
'No idea' she had twins
Although Lindiwe died within a week of giving birth to her babies, she lived long enough to tell her family of the events on the day they were born.
Lindiwe was transferred to KwaMhlanga from a clinic in the neighbouring village after staff raised concern about her blood pressure.
"They [the doctors at KwaMhlanga Hospital] performed a Caesarean section. But they had no idea she was expecting twins," Msiza says.
"After taking out the first baby, they started to stitch her up. But my daughter said she told them that she could feel that there was another baby moving inside.
"They had to remove the stitches and open her tummy again. That's when they saw the second baby and took him out."
Lindiwe was discharged from the hospital three days after having her twins.
Msiza remembers packing pink dresses in Lindiwe's hospital bag. "We didn't know she was having twins. Her doctor said she was expecting a baby girl. I don't know how her doctor came to that conclusion."
Msiza says Lindiwe was bleeding profusely after her Caesarean section on the day she was discharged.
"The operation was not complete. The cut ran across her stomach and the sides were still open because there were no stitches there. I would clean her wounds with Savlon every day, hoping that the wound would close as it healed," she says.
The Mpumalanga health department says it has never heard of Lindiwe's case.
In response to the Mail & Guardian's inquiry, the hospital's clinical manager, Sokolakamo Losilo, said that when Lindiwe got to the hospital, she was anaemic and had high blood pressure. He said the operation "went fine and there was no bleeding". In fact, he said, clinic records stated that her operation was healing well.
Joy at boy's birth short-lived
On the other side of the single tar road that runs through the village, in a crumbling mud house planted at the far end of a huge barren yard, Winnie Makalateng sits on the dusty stoep in front of her kitchen door.
She looks at photographs of her grandson's christening.
With shaking hands she puts the photographs back into a plastic envelope and folds them in her lap as she struggles to regain her composure. The first anniversary of her daughter's death is approaching. Glenda would have been 32 this year.
"Glenda left home for KwaMhlanga to give birth. She spent two weeks at KwaMhlanga Hospital saying that she was not feeling well and was struggling to breathe," Makalateng says.
"On November 30, she called and told me that she had had a baby boy. I was so excited, I ululated."
But her joy was short-lived. At about 8pm that night, she got a phone call from the hospital. The nurse said she must get there immediately because Glenda was fainting and foaming at the mouth. Makalateng was driven to the hospital by a neighbour.
"When I got there, they told me that Glenda had passed away. She had had a baby boy but she had died. When I asked what happened, they said they didn't know, that she just started foaming at the mouth, screamed and died."
Martha Mabena is stuck in a broken wheelchair. She gave birth to a baby boy naturally at the Kwaggafontein clinic, one of KwaMhlanga's feeder clinics, in July last year and was discharged the next morning.
However, what the attending nurse had not discovered was that there was another baby left in her womb. She was in fact pregnant with twins.
"A few days later I became disorientated and started to vomit. I didn't want to go to KwaMhlanga for help, so we drove to an academic hospital in Pretoria. There they discovered that I was still pregnant: the one baby was still in me. But, by now, he was dead."
Doctors removed the baby. "I was so disorientated, I can hardly remember how they did that. Only my boyfriend – the father of my child – saw my baby. I'll never know what she looked like. All I know is that it was a baby girl."
People should 'lodge complaints'
According to the Mpumalanga health spokesperson, Ronnie Masilela, those who feel that they have been mistreated must lodge complaints with the department so that they can be looked into.
"[We] are not aware of cases of alleged negligence as these have not been reported to the department. The department investigates each case of alleged negligence as soon as it is brought to [its] attention."
But none of these women lodged complaints. They either did not know that they could or were too tired to do so. "You can't cry over spilt milk. What is done is done," says Msiza. All she wants is to know how her daughter died.
Baphasile Mthimunye is a lawyer from the community who has several clients who have complained to him about the hospital's maternity wards.
"It's rural here and most people are illiterate. They don't know how health department procedures work. They're helpless.
"Just this week, I received a phone call from the brother of a woman who gave birth at the hospital this past weekend," Mthimunye says. "He said that, during the process of birth, the child's arm was broken. I don't have the full details on that because they were calling to make an appointment to see me."
According to Masilela, the provincial health department incurred R5 762 089 in litigation for medical neglect related to pregnancy and childbirth in the province for the 2012/13 financial year.
But, he says: "It should be stated that, at KwaMhlanga Hospital for the last financial year, no litigation costs were incurred for this type of medical [negligence]."
KwaMhlanga at odds with provincial average
This is despite the fact that, according to the department, the maternal mortality rate – the number of women who die during pregnancy, childbirth or within 42 days thereafter – at KwaMhlanga, is 251 deaths per 100 000 live births, much higher than the provincial average of 179. The national figure is 269 – six times higher than that the goal of 38 per 100 000 births that the United Nations has set for South Africa.
Figures from the latest District Health Barometer, which provides an overview of primary healthcare statistics, show that Mpumalanga is the only province to show an increase in maternal deaths in health facilities in the past year.
A staff member at KwaMhlanga who asked not to be named says the hospital's maternal mortality rate is the highest in the province.
According to a government report on maternal mortality, Saving Mothers, most women give birth in district and regional hospitals like KwaMhlanga. Excessive bleeding during or after childbirth – or obstetric haemorrhage – is the second leading cause of maternal death after HIV.
Eight out of 10 deaths due to obstetric haemorrhage are thought to be avoidable, according to the report. Obstetric haemorrhage is the most common avoidable cause of maternal death. Of these, excessive bleeding related to a Caesarean section is the leading cause. Most excessive bleeding happens during and after a Caesarean section and occurs in level one and two health facilities, the report says.
Level one hospitals – of which the 153-bed KwaMhlanga is one – refers to the number of patients it serves.
Policies for mothers
In an opinion piece in the Mail & Guardian in September, the national health department's maternal-health team said it had initiated several policies to deal with the country's high maternal mortality rates. These include providing obstetric ambulances and the training of doctors and midwives in managing pregnancy- and childbirth-related emergencies.
"But these policies have obviously not reached us," says Msiza. "If they had, my daughter would not have been dead."
Health department figures show that Mpumalanga has only three full-time gynaecologists for the province's entire public health service.
The Democratic Alliance's health spokesperson for Mpumalanga, James Masango, says most health professionals at the KwaMhlanga Hospital are not full-time employees but consultants – that is, doctors employed elsewhere working at the hospital on a part-time basis.
He says the Mpumalanga health department spent R2.4-billion on consultants over the past three years.
"Ninety-five posts for health professionals at KwaMhlanga Hospital alone were advertised in April this year and interviews conducted, but the department refused to appoint these much-needed professionals because of budget constraints. Instead, they have been given appointment letters without any starting date."
According to a source, staff turnover at the hospital is extremely high: six doctors resigned between January and June this year and haven't been replaced.
A nurse, who asked not to be named for fear of victimisation, says staff at the hospital, and nurses in particular, "are at risk of litigation because we are overwhelmed" and "overworked, and end up making mistakes" because they often have to work without the supervision of doctors.
She says doctors come and go as they please and cover for each other. They would simply clock in and then disappear.
"They do each other favours at our expense. They wander off because they know the nurses will be there to do the work. Often nurses are left to deal with duties that are not ours because the doctor is not around.
"When the patient dies, the nurses are blamed. But when the patient survives the doctors are praised, even if they were not there."
The nurse says they are left to account for patient deaths because it is the nurses who are at the patient's beck and call. Nurses become "aggressive because of the working conditions" at the hospital.
"Staff turnover at the hospital is high. Nurses resign in droves because the threat of litigation they are under can jeopardise their careers."
She says that most community members "appreciate what we are doing". For those who are not happy with the service, "they must make use of the suggestion box and complaints".
Selena Msiza's daughter died a week after her daughter's twins were delivered by Caesarean-section. (Clarissa Sosin)
Hospital turned into an 'abattoir'
Back at her house, Msiza covers her eyes with her worn hands, blinking back her tears.
"They [the staff at KwaMhlanga] have taken that hospital and turned it into a slagpaal [abattoir].
"It's not there to heal people it's there to kill them. It's like we're not even human. As long as they get paid at the end of the month, they don't care about anything else," she says.
"We still don't know what killed her [Lindiwe]. I think it was the amniotic sack. I don't think that they removed it when they took out the second baby. I still don't understand how they missed the other baby.
"But that is the only hospital we have access to. When we go to the hospital in Dennilton [in Limpopo] it refers us back to KwaMhlanga."
Msiza says she is struggling to make peace with the situation because nobody seems willing to take responsibility for Lindiwe's death.
"I blame myself completely. I keep thinking, if only I had taken my child to Kalafong Hospital [in Pretoria], she would still be alive.
"I can't sleep at night. It's as if she'll come walking through the door at any moment because she said she would be back. But how will she come back when I sent her to KwaMhlanga to die?"
?SA struggling to curb maternal deaths
With slightly fewer than 800 days left for South Africa to meet the target set by the United Nations to reduce the number of women who die during pregnancy, childbirth or within 42 days afterwards to 38 per 100 000 births, the country is lagging far behind.
The target is to reduce the 1990 maternal mortality figures by 75%. But maternal deaths in South Africa increased from 250 deaths per 100 000 live births in 1990 to a peak of 360 deaths per 100 000 live births in 2005, according to the UN.
The latest government estimates of 269 deaths per 100 000 live births is not only higher than the 1990 figures but it is also more than six times the target South Africa is supposed to achieve by 2015.
Countries with far fewer resources and much lower gross domestic products than South Africa have made more progress in meeting the UN's millennium development goals. Most notable is Eritrea, which reduced its maternal mortality rates by 73% between 1990 and 2010 from 880 per 100 000 to 240. The country's rate is now lower than that of South Africa's.
Equatorial Guinea and Rwanda reduced their maternal mortality rates for the same period by 81% and 73% respectively. Equatorial Guinea's rate of 240 is also lower than South Africa's.
A senior official in the health department, who asked not to be named, said South Africa can drastically reduce maternal mortality by getting "the basics right", such as preventing bleeding during and after childbirth.
A government report has attributed 40% of maternal deaths to HIV but gynaecologist Eddie Mhlanga from the Mpumalanga health department told the Mail & Guardian earlier this year that negligence, substandard care and mismanagement in maternal wards would have to be addressed first.
Mhlanga is the former head of maternal health in the national health department and Mpumalanga has one of the highest maternal mortality rates in the country.
"One may have the best drugs in the world but, if there is no proper care during labour and delivery, it is of no use. The patient may have antiretroviral treatment but, if she is not treated for bleeding after delivery, she will die – not from HIV but from postpartum haemorrhage," Mhlanga said.