Enhancing South African maternal care within the public health system : a case of stillbirths in the Lejweleputswa District Municipality

Abstract

Maternal and perinatal health remain urgent public health concerns in South Africa, particularly in rural and underserved regions like the Lejweleputswa District of the Free State Province. Despite the presence of established maternal health policies, persistently high stillbirth rates expose deep-seated disparities in antenatal care quality and systemic inefficiencies within the public healthcare system. This study investigates the multifactorial causes of stillbirths in Lejweleputswa and proposes actionable strategies to strengthen maternal healthcare delivery and reduce preventable perinatal deaths. The study pursued six key objectives: (a) to investigate the underlying causes and determinants of stillbirths in the district; (b) to examine the effect of socio-economic factors on antenatal care quality and stillbirth outcomes; (c) to assess awareness and utilization of antenatal and obstetric services; (d) to analyze healthcare providers’ knowledge and practices regarding stillbirth prevention; (e) to evaluate maternal healthcare services, including infrastructure, staffing, and quality; and (f) to develop a model that addresses stillbirth risk factors. A mixed-methods approach was adopted, combining quantitative data from 263 healthcare workers with qualitative interviews from midwives, nurses, and medical officers. The study validated a behavioral stillbirth prevention model anchored in the Andersen model of healthcare utilization using confirmatory factor analysis (CFA) and structural equation modeling (SEM). Quantitative findings highlighted significant links between stillbirth risk and maternal conditions such as hypertension, HIV, diabetes, and advanced maternal age. Socio-economic status and healthcare access were shown to shape ANC utilization. SEM analysis revealed that maternal healthcare attitudes significantly predicted ANC practices (β = 0.551, p < 0.001), which in turn influenced perceived service quality (β = 0.587, p < 0.001) and infant outcomes (β = 0.240, p = 0.001). Service quality itself strongly predicted infant outcomes (β = 0.386, p < 0.001). However, attitudes alone did not directly predict service quality, emphasizing the gap between knowledge and action. The qualitative insights revealed that health system inefficiencies, negative provider attitudes, cultural stigma, and financial barriers discourage early and consistent ANC attendance, despite relatively high levels of service awareness. The study concludes that stillbirth prevention requires integrated, multi-level strategies combining clinical, infrastructural, socio-economic, and culturally sensitive interventions to improve maternal and neonatal health outcomes in the district.