Postgraduate Training Course in Reproductive Health 2004

The global incidence of puerperal sepsis

Maureen Chisembele, MD
Department of Obstetrics and Gynaecology, University Teaching Hospital
Lusaka, Zambia

See also presentation

Abstract

Background

Puerperal sepsis is an important cause of maternal morbidity and mortality.

Objective

To assess the incidence of puerperal sepsis worldwide. This is part of a Systematic Review on the Epidemiological Evidence for Maternal Morbidity and Mortality which is currently being done.

Search Strategy

The following data bases will be searched; Medline, Econlit, Biosis, EMBASE,Popline, Cinahl, Pias International, CAB, Sociofile, the gray literature database (SIGLE), Cochrane Data of Systematic Reviews, The Database of Abstracts of Reviews of Effectiveness and The Cochrane Controlled Trials Register. Hand searching of journals will be done. Experts in the field will be contacted.

Selection Criteria

Study designs providing prevalence or incidence rates for any puerperal sepsis in any population will be included for assessment. These will included various studies designs such as cross-sectional, cohort, clinical trials and surveys.

Exclusion Criteria:

  • Reports with no data

  • Reports providing only statements of puerperal sepsis but without any source of data that can be tracked

  • Reports referring to data before 1990, unless disaggregation will  not be possible, so therefore, data for the whole period will then be included, but not for studies that will include years from earlier than 1980

  • Reports where dates for data collection periods are not provided

Data Collection and Analysis

A data extraction form will be used to collect data from included studies. Stratified analyses will be conducted.

Background

Sepsis is among the leading causes of preventable maternal death. In a study of maternal mortality in a tertiary care hospital in Abbottabad to determine causes and preventable factors, the contribution of sepsis to maternal deaths was 19.2% and it was the third leading cause of death (24). In the state of Anambra of Nigeria, a study showed that sepsis was the fourth leading cause of death and contributed 12.1% to the maternal deaths (6). In Pakistan, sepsis was among the three leading causes of death in both hospitals and the community (18).  In Europe and the western countries, sepsis continues to be a major contributor to maternal deaths even though the rate of maternal deaths has drastically gone down. A review covering a period of 20 years, in Norway, on the number and causes of maternal deaths, postpartum sepsis accounted for 4 of the 47 deaths (10%) and was the third leading cause of death (20). In Poland over a 10-year period, 462 maternal deaths were recorded and sepsis accounted for 27.3% of the direct maternal deaths and was the second leading cause of death (21).  Puerperal Sepsis is defined in the International Classification of Diseases (ICD-10), as a ‘temperature rise above 38.0 C maintained over 24 hours or recurring during the period from the end of the first to the end of the tenth day after childbirth or abortion’ (3). Alternatively, the United States Joint Commission on Maternal Welfare uses a standard definition for puerperal fever used for reporting puerperal morbidity as an 'oral temperature of 38.0 C or more on any two of the first ten days postpartum' (1).  The predisposing factors or conditions leading to the development of maternal sepsis can be quite varied. These include; a home birth in unhygienic conditions, low socioeconomic status, anaemia, primiparity prolonged rupture of membranes, multiple vaginal examinations, prolonged labour and obstetrical manoeuvres (9). An underlying infection such as HIV/AIDS may contribute to a woman’s susceptibility to sepsis (25).
Sepsis is an important morbid condition because of its consequences on both fetal and maternal outcomes. In the mother, some of the immediate consequences include septicaemia, endotoxic shock or the development of peritonitis or abscess formation leading to surgery. In the fetus, some of the consequences include a depressed five-minute Apgar Score, neonatal septicaemia, and pneumonia, to mention but a few.Sepsis significantly affects morbidity and mortality. Puerperal sepsis was found to be the most frequent morbidity in a study on obstructed labour in the State of Gombe in Nigeria (22). A study on ‘Maternal Intensive Care and Near-miss Mortality' in Canada, showed sepsis to be the third main reason for transfer to intensive care unit and accounted for 15% of cases (7). This was also observed in Brazil where sepsis was among the leading causes of transfer to intensive care unit (19). In South Africa, sepsis is one of the main indications for emergency peripartum hysterectomy (15).
Sepsis is reported to be a major complication of induced abortion in Nigeria (23).  In India, a study showed that 50% of maternal deaths due to sepsis were related to unsafe induced abortion (2). Sepsis has been shown to have a very high case fatality rate. A study on the ‘Incidence and Case Fatality Rates’ in West Africa looking at severe maternal morbidity from direct obstetric causes, showed sepsis to have a case fatality rate of 33.3% (11). The incidence of puerperal sepsis shows variations among published reports. In Nigeria, for example, two studies showed an incidence of puerperal sepsis of 1.49 and 1.36% respectively 4,8. Even lower rates of puerperal sepsis have been reported in West Africa, as low as 0.09% (11). The picture is the same in Malawi, where incidence rates of 1.34% have been reported (12). A slightly higher incident rate was observed in one study in Sierra Leone of 5.38%, but this could be due to the relatively few numbers of women seen compared to other studies (5). In industrialized countries such as the United States and Canada, the incidence rates for puerperal sepsis are generally not much higher than in the developing countries. Few studies report incidence rates over 5.0% (10 14, 16). One study in Australia reported an incidence rate of puerperal sepsis of 17% (17) but this study was looking at a population already at risk for puerperal sepsis and endometritis. Another study in New Zealand reported rate of 10.9% but this could be attributed to the relatively fewer numbers of study subjects as was the case with the study in Sierra Leone.  Interestingly, a higher incidence rate is reported in one study in the United States where the study population may be considered to be of a similar background to those in developing countries. This study looked at women from low socioeconomic backgrounds and reported an incidence rate of 6.18% (13).
A systematic review summarizing the true extent of puerperal sepsis would help shed more light. Although sepsis is an important public health problem contributing to maternal morbidity and mortality, information on the global magnitude of the problem is limited. Studies reporting incidences of sepsis are widely dispersed in the literature. The provision of the true picture of the problem would better inform decision making in planning of healthcare particularly in developing countries.

Objective

The aim of this review is to provide the incidence or prevalence data on the contribution of puerperal sepsis world wide.

Methods

Criteria for Considering Studies

  • Types of Studies

    • Any study design including cross-sectional, cohort, clinical trials, and surveys having incidence or prevalence data on puerperal sepsis.

  • Types of Participants

    • Women within 42 days of termination of pregnancy

  • Types of Interventions

    • None

  • Types of Outcome Measures

    • Puerperal sepsis

Search Strategy

The following data bases will be searched; Medline, Econlit, Biosis, EMBASE,Popline, Cinahl, Pias International, CAB, Sociofile, the gray literature database (SIGLE), Cochrane Data of Systematic Reviews, The Database of Abstracts of Reviews of Effectiveness and the Cochrane Controlled Trials Register. Hand searching of journals will be done. Experts in the field will be contacted. The review will cover both published and unpublished studies dated from 1997 to 2002

Selection Criteria

Study designs providing prevalence or incidence rates for any puerperal sepsis in any population will be included for assessment.

Exclusion Criteria

  • Studies with no data
  • Reports providing only statements of puerperal sepsis but without any source of data that can be tracked
  • Reports referring to data collected before 1990, unless desegregation will not be possible, so therefore, data for the whole period will be included, but not for studies that include years from earlier than 1980

Studies where no dates for data collection periods are provided

Methods of the review

All studies identified by the search strategy will be assessed by looking at titles and abstracts first. Those deemed to be relevant at this stage will be retrieved and full-text evaluation will be made. A data extraction form designed specifically will be used to extract data from the included studies. The data extraction form will be designed so as to extract information on important characteristics of the studies such as design, population setting characteristics, follow-up and completeness of data. Stratified analyses of data will be conducted.

The review is expected to be completed by the end of 2004.

References

  1. Wager GP, Martin DH, Koutsky L, Eschenbach DA, Daling JR, Chiang WT, Alexander ER, Holmes KK. Puerperal infectious morbidity: relationship to route of delivery and to antepartum Chlamydia trachomatis infection. Am J Obstet Gynecol. 1980 Dec 1;138(7 Pt 2):1028-33. [PubMed]

  2. Prakash A, Swain S, Seth A. Maternal mortality in India: current status and strategies for reduction. Indian Pediatr. 1991 Dec;28(12):1395-400. [PubMed]

  3. WHO International Classification of Diseases and related Health Problems – 10th Revision. Geneva, Switzerland: World Health Organization, 1992.

  4. Onwudiegwu U. Effect of a Depressed economy on the utilisation of Maternal Health Services: The Nigerian Experience II. Journal of Obstetric and Gynae, 1997 vol 17. No 2, 143-148.

  5. Leigh B, Kandeh HB, Kanu MS, Kuteh M, Palmer IS, Daoh KS, Moseray F.  Improving emergency obstetric care at a district hospital, Makeni, Sierra Leone. The Freetown/Makeni PMM Team. Int J Gynaecol Obstet. 1997 Nov;59 Suppl 2:S55-65. [PubMed]

  6. Chukudebelu WO, Ozumba BC. Maternal mortality in Anambra State of Nigeria. Int J Gynaecol Obstet. 1988 Dec;27(3):365-70. Review. [PubMed]

  7. Baskett TF, Sternadel J.. Maternal intensive care and near-miss mortality in obstetrics. Br J Obstet Gynaecol. 1998 Sep;105(9):981-4. [PubMed]

  8. Chiwuze J, Oronsaye AU, Okolocha C, Onoguwe B. Factors associated with high maternal morbidity and mortality in Ekpoma, Nigeria. African J Med Pract 1998, 5(4):187-93.

  9. Dare FO, Bako AU, Ezechi OC.  Puerperal sepsis: a preventable post-partum complication. Trop Doct. 1998 Apr;28(2):92-5. [PubMed]

  10. Seoane G, Castrillo M, O'Rourke K. A Validation Study of Maternal Self Reports of Obstetrical Complications: Implications for Health Survey. In J Obstet Gynae 1998, 62 ,229-236.

  11. Prual A, Bouvier-Colle MH, de Bernis L, Breart G. Severe maternal morbidity from direct obstetric causes in West Africa: incidence and case fatality rates. Bull World Health Organ. 2000;78(5):593-602. [PubMed]

  12. Kulmala T, Vaahtera M, Rannikko J, Ndekha M, Cullinan T, Salin ML, Ashorn P.  The relationship between antenatal risk characteristics, place of delivery and adverse delivery outcome in rural Malawi. Acta Obstet Gynecol Scand. 2000 Nov;79(11):984-90. [PubMed]

  13. Tamura T, Goldenberg RL, Johnston KE, DuBard M.  Maternal Plasma Zinc Concentration and Pregnancy Outcomes. Am J  Clin Nutr 2000, 71:109-13. [PubMed]

  14. Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. First-birth cesarean and placental abruption or previa at second birth(1). Obstet Gynecol. 2001 May;97(5 Pt 1):765-9. [PubMed]

  15. Sebitloane MH, Moodley J. Emergency peripartum hysterectomy. East Afr Med J. 2001 Feb;78(2):70-4. [PubMed]

  16. Kabiru WN, Jamieson D, Graves W, Lindsay M. Trends in operative vaginal delivery rates and associated maternal complication rates in an inner-city hospital. Am J Obstet Gynecol. 2001 May;184(6):1112-4. [PubMed]

  17. Creedy DK, Noy DL. Postdischarge surveillance after cesarean section. Birth. 2001 Dec;28(4):264-9. [PubMed]

  18. Jafarey SN. Maternal mortality in Pakistan--compilation of available data. J Pak Med Assoc. 2002 Dec;52(12):539-44. [PubMed]

  19. Dias de Souza JP, Duarte G, Basile-Filho A. Near-miss maternal mortality in developing countries. Eur J Obstet Gynecol Reprod Biol. 2002 Aug 5;104(1):80.[PubMed]

  20. Vangen S, Bergsjo P. [Do women die from pregnancy these days?] Tidsskr Nor Laegeforen. 2003 Dec 23;123(24):3544-5. [PubMed]

  21. Troszynski M, Chazan B, Kowalska B, Jaczynska R, Filipp E. Four main reasons of maternal death in Poland between 1991-2000] Ginekol Pol. 2003 Oct;74(10):1306-15. [PubMed]

  22. Melah GS, El-Nafaty AU, Massa AA, Audu BM. Obstructed labour: a public health problem in Gombe, Gombe State, Nigeria. J Obstet Gynaecol. 2003 Jul;23(4):369-73. [PubMed]

  23. Ikechebelu JI, Okoli CC. Morbidity and mortality following induced abortion in Nnewi, Nigeria. Trop Doct. 2003 Jul;33(3):170-2. [PubMed]

  24. Begum S, Aziz-un-Nisa, Begum I. Analysis of Maternal Mortality in a tertiary care Hospital to determine causes and preventable factors. Jayub Med Coll Abbottabad. 2003 Apr-Jun;15(2): 49-52

  25. McIntyre J. Mothers infected with HIV. Br Med Bull. 2003;67:127-35. Review. [PubMed]

 

 

 
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