Puerperal Sepsis Global Overview Global Forum on Bacterial Infections & Antibiotic Resistance New Delhi, October 2011

Jeffrey Smith, MD, MPH Maternal Health Director

Seth Rosenblatt, MPH Sr. Program Officer MCHIP / Jhpiego

Causes of Maternal Death

§  Hemorrhage §  Sepsis §  Eclampsia §  Abortion §  Obstructed labor §  HIV

§  75% of maternal death due to 5 main causes

Khan LANCET 2007

2

Contributing Factors and Prevention

Contributing Factors §  Prolonged labor §  Prolonged rupture of

membranes §  Unhygienic labor practices §  Multiple cervical exams

Preventative Strategies §  Partograph §  Labor hygiene

3

Global Survey on Puerperal Infection Prevention and Management

§  Questions about clinical guidance and actual practice

§  Preventative measures and management

§  Responses from MCHIP implementing programs: 20/28 countries

COUNTRIES Afghanistan Madagascar Bangladesh Malawi Bolivia Mozambique Ethiopia Malawi Ghana Nigeria Guinea Paraguay India Rwanda Indonesia Tanzania Kenya Zambia Liberia Zimbabwe

4

Antibiotics for Birth or Episiotomy: Policy and Practice

0%  

100%  

Na#onal  clinical  guidelines  recommend      prophylac#c  an#bio#cs  for  normal  birth?  

Yes  

No    

20%  

80%  

Do  most  providers  rou#nely  use  prophylac#c  an#bio#cs  

for  normal  birth?  

Yes  

No  

0%  

100%  

Na#onal  clinical  guidelines  recommend    prophylac#c  an#bio#cs  for  episiotomy?    

Yes  

No  

20%  

80%  

Do  most  providers  rou#nely  use  an#bio#cs  for  

episiotomy?  

Yes  

No  

Afghanistan  

Bangladesh  

Bolivia  

Ethioipa  

Ghana  

Guinea  

India    

Indonesia  

Kenya  

Liberia  

Madagascar  

Malaw

i  

Mozam

bique  

Nepal  

Nigeria  

Paraguay  

Rwanda  

Tanzania  

Zambia  

Zimbabw

e  

YES  

NO  

Antibiotic Prophylaxis for Procedures

Afghanistan  

Bangladesh  

Bolivia  

Ethioipa  

Ghana  

Guinea  

India    

Indonesia  

Kenya  

Liberia  

Madagascar  

Malaw

i  

Mozam

bique  

Nepal  

Nigeria  

Paraguay  

Rwanda  

Tanzania  

Zambia  

Zimbabw

e  

Y  E  S  

NO  

70%  

30%  

Prophylac#c  an#bio#cs  before  caesarian  sec#on  

Yes  

No  60%  

40%  

Prophylac#c  an#bio#cs  before  manual  removal  of  placenta  

Yes  

No  

Guidelines on Cervical Exams and AROM

Afghanistan  

Bangladesh  

Bolivia  

Ethioipa  

Ghana  

Guinea  

India    

Indonesia  

Kenya  

Liberia  

Madagascar  

Malaw

i  

Mozam

bique  

Nepal  

Nigeria  

Paraguay  

Rwanda  

Tanzania  

Zambia  

Zimbabw

e  

YES  

NO  

95%  

5%  

Na#onal  clinical  guidelines:  Frequency  of  cervical  exams  during  labor?  

Yes  

No  

90%  

10%  

Na#onal  clinical  guidelines:    When  to  perform  ar#ficial  rupture  of  membranes?  

Yes  

No  

Antibiotics to Treat Chorioamnionitis or Endometritis

8 100%  

0%  

Na#onal  clinical  guidelines  on  use  of  an#bio#cs    to  treat  

chorioamnioni#s?  

Yes  

No  90%  

10%  

Na#onal  clinical  guidelines  on  use  of  an#bio#cs    to  treat  puerperal  

endometri#s?    

Yes  

No  75%  

25%  

Na#onal  clinical  guidelines  on  how  long  to  treat  endometri#s  

with  an#bio#cs?    

Yes  

No  

Afghanistan  

Bangladesh  

Bolivia  

Ethioipa  

Ghana  

Guinea  

India    

Indonesia  

Kenya  

Liberia  

Madagascar  

Malaw

i  

Mozam

bique  

Nepal  

Nigeria  

Paraguay  

Rwanda  

Tanzania  

Zambia  

Zimbabw

e  

YES  

NO

9

Quality of Care Surveys 2010

§  By MCHIP and host countries

§  Direct observation of clinical practices

§  5 countries: Kenya, Tanzania, Ethiopia, Madagascar and Rwanda

Availability of infection prevention supplies in the delivery room

Notes: Bars represent average of mean scores for all countries and high-low error bars show the by-country range.

N= 597 facilities

73% 96% 90% 88% 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Soap and piped water/bucket with tap

Sharps container Already mixed decontaminating solution

Clean (or sterile) gloves

Quality of infection prevention during labor & delivery

41%

40%

92%

57%

94%

87%

95%

30%

75%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Initial assessment: Washes his/her hands before any examination

1st stage: Washes his/her hands before any examination

Wears high-level disinfected or sterile gloves for vaginal examination

Puts on clean protective clothing in preparation for birth

Disposes of all sharps in puncture-proof container

Decontaminates all reusable instruments in 0.5% chlorine solution

Disposes of all contaminated waste in leakproof containers

Wipes apron with 0.5% chlorine solution

Washes hands after birth

Notes: Bars represent average of mean scores for all countries and high-low error bars show the by-country range.

N= 2164 observations

Quality of partograph use

58% 45% 23% 36% 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Partograph used during labor

Partograph initiated at appropriate time

Plotted at least every half hour during labor

Delivery information recorded

Notes: Bars represent average of mean scores for all countries and high-low error bars show the by-country range.

N= 2164 observations

Conclusions

§  Prevention, early diagnosis and proper treatment of maternal infection crucial

§  Policies and guidelines on IP and use of ABX are generally accurate

§  Practices do not always conform to national guidelines

§  Further understanding of approaches for prevention and management of maternal infection is needed

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