The global incidence of puerperal sepsis
Maureen Chisembele, MD
Department of Obstetrics and Gynaecology, University Teaching Hospital
See also presentation
Puerperal sepsis is an important cause of maternal morbidity and mortality.
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.
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.
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.
- 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.
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.
The aim of this review is to provide the incidence or prevalence data on the contribution of puerperal sepsis world wide.
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
- Types of Outcome Measures
- Puerperal sepsis
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
Study designs providing prevalence or incidence rates for any puerperal sepsis in any population will be included for assessment.
- 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.
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