Prevalence and Factors Associated With Puerperal Sepsis among Postnatal Women at Queen Elizabeth Central Hospital, Blantyre by Priscabell Ndasauka Kalumbi
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Date
15-07-21
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Kamuzu University of Health Sciencies
Abstract
Executive Summary
Study Type: An analytical cross-sectional study of hospital records.
The problem: Globally 6 million women developed puerperal sepsis and around 77,000
mothers died from it in 2017(Atlaw et al,2017). Puerperal sepsis is the fifth common cause
of maternal mortality worldwide. In Malawi a confidential inquiry into maternal deaths
indicated that puerperal sepsis is the leading cause of maternal death (MOH, 2019) and it
contributes to 9.3 % of all maternal deaths in the country. Anecdotal statistics from Queen
Elizabeth Central Hospital(QECH) in 2019 showed there are 12.2 % puerperal sepsis cases
out of 30 % caesarean section deliveries performed (QECH, HMIS ,2019). Despite its great
impact on maternal mortality and morbidity, there is not enough literature on the prevalence
and associated factors of puerperal sepsis among postnatal mothers in Malawi. With this
backdrop, the aim of this study is to estimate prevalence and associated factors of puerperal
sepsis among postnatal mothers at Queen Elizabeth Central Hospital - a tertiary referral
hospital in Malawi.
Objectives
Main Objective
To determine prevalence and associated factors of puerperal sepsis among postnatal mothers
at Queen Elizabeth Central Hospital.
Specific Objectives
1. To describe the demographic and clinical characteristics of women with puerperal sepsis
during the postpartum period at Queen Elizabeth Central Hospital.
2. To determine factors associated with puerperal sepsis in postpartum women at Queen
Elizabeth Central Hospital.
3. To assess relationship between puerperal risk factors and poor maternal outcomes at
Queen Elizabeth Central Hospital.
Methodology
This study will deploy an analytical cross-sectional design with a non-predetermined sample
size of postnatal women records in Chatinkha postnatal ward. Purposive total sampling
technique will be used to select the study participants into the study. Data will be extracted
from files of patients admitted from January 2020 to June 2020 and analysed using SPSS
version 20. The data will be presented in form of percentages, frequencies through tables,
graphs and charts. Logistic regression will be used to establish relationship between maternal
factors and poor outcomes.
Possible Constraints
The major constraint in the study is missing data from the use of medical records. Multiple
imputation will be done where data is missing.
Expected Findings
This will study will describe the burden of puerperal sepsis in postpartum women in QECH
and Identify factors associated with it. The generated data will help health care providers
and policy makers to develop interventions that focus on the primary causes of sepsis and
prioritise the factors that will be associated with Sepsis. . It will also enable policy-makers
and managers to consider integrating puerperal sepsis education with emphasis on factors
that have shown to have poor maternal outcomes.
Expected findings and dissemination:
The results will be presented in tables showing summary statistics and odds ratios.
A final master’s dissertation will be written and presented to the post graduate committee at
the Kamuzu College of Nursing. The final dissertation will be shared with the Kamuzu
College of Nursing library and The College of Medicine Research and Ethics Committee.
Results from this research will be published in an open access peer reviewed journal and
presented at research dissemination conferences.
Background information and introduction
Introduction
Puerperal Sepsis has been defined by the World Health Organization as the infection
of the genital tract occurring at any time between the onset of labour, rupture of membranes
and the 42nd day postpartum. The Puerperal sepsis presents commonly with fever (oral
temperature of 38.5 degrees Celsius or higher on any given occasion) and other symptoms
such as pelvic pain, abnormal vaginal discharge, abnormal smell/foul odour discharge or
delay in uterine involution (less than 2cm/day) during the first eight days (WHO, 2015).
Puerperal sepsis accounts for a substantial contribution to the Maternal Mortality
Rate (MMR). Global estimates suggest that direct (obstetric) infections are the third most
common cause of maternal mortality, representing about 10.7% of deaths, a majority of
which occur in Low- and Middle-Income Countries (LMIC) (WHO, 2020). The toll is higher
in LMICs compared to high income countries (HICs) (Say et.al., 2014). In sub-Saharan
Africa, maternal sepsis is one of the leading causes of over 70% of maternal deaths, others
include: haemorrhage, hypertension disorders, unsafe abortion, and obstructed labour
(Dillen et.al., 2010). Maternal sepsis, specifically, contributes 10.3% of all cause maternal
deaths in SSA (Bonnet et.al., 2018).
The Global Burden of Diseases Study reported a 30 % prevalence of maternal sepsis
(James et al., 2018). A WHO maternal sepsis cohort study conducted in 713 health facilities found that 70.4 out of 1000 live births reported to health facilities with an infection
(puerperal sepsis) (Group, 2020). Recent estimates suggest that in sub–Saharan Africa (SSA)
the burden is highest compared to other regions with sepsis accounting for up to 45% (Rudd
et.al., 2020). However, reliable estimates of the incidence and mortality of maternal sepsis
in sub-Saharan Africa are incomplete (Otu et.al., 2020).
In Malawi, a confidential inquiry showed that puerperal sepsis is the leading cause
of maternal mortality accounting for 9.3 % of maternal deaths (MOH, 2019). Nevertheless,
there is no programmatic interventions focused on prevention of puerperal sepsis. Malawi
participated in the WHO-led Global Maternal Sepsis Study (GLOSS) and Awareness
Campaign umbrella of the “Global Maternal and Neonatal Sepsis Initiative” the aims of
which were to assess the burden of maternal sepsis, validate the identification criteria and
raise awareness of maternal sepsis among health care workers. However, there is no evidence
of Malawi’s implementation of this study following the campaign (GLOSS, 2017).
According to Brizuela et.al., (2020), evaluation of countries that implemented the campaign
shows improvements in service provision, reduced overall risk of mortality and morbidity
from maternal sepsis in high-income as well as in low-income countries.
The Malawi Emergency Obstetric and New-born Care Needs Assessment results
showed that puerperal sepsis contributes to 18.9% of direct maternal deaths (MOH,2015).
Nevertheless, there is paucity of evidence with regards to the epidemiology (when, where,
who, what and why) of sepsis in maternal mortality and morbidity burden. As in many
developing countries many cases of puerperal infections can go undiagnosed and underreported
(Panelope et al., 2013).
Hospital-based anecdotal evidence suggests that puerperal sepsis potentially carries
the biggest morbidity burden at Queen Elizabeth Central Hospital, a tertiary hospital in
southern Malawi. According to 2019 hospital records, there were over 2911 caesarean section deliveries performed at Queen Elizabeth Central Hospital (QECH), comprising 38
% of the total deliveries; 12.2% of these deliveries developed puerperal sepsis within 42
days of post-delivery (QECH HMIS, 2019). Given that puerperal sepsis significantly
contributes to preventable maternal morbidity and mortality, combating sepsis is an integral
part of realizing the Sustainable Development Goals (SDGs) targets 3.1 and 3.2 relating to
maternal wellbeing, as well as target 3.3 on infectious diseases (WHO, 2020). Indirectly,
sepsis is relevant to other targets in SDG 3 such as 3.8 on quality of care for all, and its
prevention and management is inherently linked with vaccination, efforts to combat
antimicrobial resistance (UN, 2020). For Malawi to achieve this lofty goal, reduction of
maternal mortality rate must set targets that need urgent achievement. Consequently,
identifying potential contributors or determinants to maternal mortality would assist in
having focused interventions that respond to the specific causes of the problem. Sepsis is an
ever-changing problem. The patterns of sepsis have been shown to differ in time. One of the
factors related to the changes in patterns has been the increasing antimicrobial resistance.
While several attempts have made to quantify the burden of sepsis by estimating the
prevalence, not many have studied the factors associated with it at the individual level in
Malawi. Hence the need for this study to bring evidence for developing of policies and
guidelines to address the problem.
Background
Puerperal sepsis is a preventable postpartum complication, and has the potential to
quickly progress to septic shock, which can eventually result into death (GLOSS, 2017). The
global incidence of puerperal sepsis is 4.4 per 100 live births (Taskin et. al., 2016) and case
fatality as high as 30-50 % has been reported in Low- and Middle-Income Countries
(UNFPA, 2012). Regional disparities in the prevalence of puerperal sepsis exist. According