Frequency and management of maternal infection in health facilities in 52 countries (GLOSS): a 1-week inception cohort study

Abstract

Background: Maternal infections are an important cause of maternal mortality and severe maternal morbidity. We report the main findings of the WHO Global Maternal Sepsis Study, which aimed to assess the frequency of maternal infections in health facilities, according to maternal characteristics and outcomes, and coverage of core practices for early identification and management.

Methods: We did a facility-based, prospective, 1-week inception cohort study in 713 health facilities providing obstetric, midwifery, or abortion care, or where women could be admitted because of complications of pregnancy, childbirth, post-partum, or post-abortion, in 52 low-income and middle-income countries (LMICs) and high-income countries (HICs). We obtained data from hospital records for all pregnant or recently pregnant women hospitalised with suspected or confirmed infection. We calculated ratios of infection and infection-related severe maternal outcomes (ie, death or near-miss) per 1000 livebirths and the proportion of intrahospital fatalities across country income groups, as well as the distribution of demographic, obstetric, clinical characteristics and outcomes, and coverage of a set of core practices for identification and management across infection severity groups.

Findings: Between Nov 28, 2017, and Dec 4, 2017, of 2965 women assessed for eligibility, 2850 pregnant or recently pregnant women with suspected or confirmed infection were included. 70·4 (95% CI 67·7-73·1) hospitalised women per 1000 livebirths had a maternal infection, and 10·9 (9·8-12·0) women per 1000 livebirths presented with infection-related (underlying or contributing cause) severe maternal outcomes. Highest ratios were observed in LMICs and the lowest in HICs. The proportion of intrahospital fatalities was 6·8% among women with severe maternal outcomes, with the highest proportion in low-income countries. Infection-related maternal deaths represented more than half of the intrahospital deaths. Around two-thirds (63·9%, n=1821) of the women had a complete set of vital signs recorded, or received antimicrobials the day of suspicion or diagnosis of the infection (70·2%, n=1875), without marked differences across severity groups.

Interpretation: The frequency of maternal infections requiring management in health facilities is high. Our results suggest that contribution of direct (obstetric) and indirect (non-obstetric) infections to overall maternal deaths is greater than previously thought. Improvement of early identification is urgently needed, as well as prompt management of women with infections in health facilities by implementing effective evidence-based practices.

Funding: UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, Merck for Mothers, and United States Agency for International Development.

Figure 1

Countries participating in the global maternal sepsis study Eligible health facilities in purposively selected geographical areas in each country participated in the study. The boundaries shown on this map do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, or concerning the delimitation of its frontiers or boundaries.

Figure 2

Study profile Percentages are shown as n of total sample. There were 713 health facilities in 52 countries. *2580 women included using full protocol, 290 women included using modified protocol in western European countries (Belgium, Denmark, Italy, Spain, the Netherlands, the UK). †Source of infection clinically, radiologically, or microbiologically confirmed. ‡Includes women who had an invasive procedure to treat the source of infection (vacuum aspiration, dilatation and curettage, wound debridement, drainage [incision, percutaneous, culdotomy], laparotomy and lavage, other surgery), admission to intensive care or high dependency unit, or transfer to another facility. §Maternal death or near-miss. ¶At least one WHO near-miss criteria. ||Includes seven deaths due to direct (obstetric) cause, five due to abortion, six due to indirect (non-obstetric) cause (respiratory infection, meningitis, gastrointestinal). **Includes two deaths due to obstetric haemorrhage, one hypertensive disorder, one other direct cause, two indirect cause, two with unknown cause.