STRENGTHS AND LIMITATIONS OF THIS STUDY
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This study examined obstetric parameters such as pre-eclampsia, birth interval, cervical cerclage, antepartum haemorrhage and postpartum haemorrhage that had not been investigated in earlier Ethiopian studies.
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Prospectively collected data from multicentre settings was used.
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The controls were added to the study at the end of the 42-day postpartum period to minimise selection and misclassification bias.
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The study relied on hospital cases and controls.
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Recall bias might have been introduced when some factors—such as the number of vaginal exams and the duration of the labour—were gathered through interviews with the women because of their absence in the medical charts.
Introduction
Puerperal sepsis (PS) is a severe inflammatory reaction to an infection caused by bacterial, viral, fungal or parasitic pathogens that occurs after childbirth, miscarriage or an unsafe abortion.1 PS may be localised in the uterus, vagina, cervix or perineum. Uterine infections can spread swiftly due to virulent organisms, compromised maternal immunity and other causes. When it extends outside the uterus, it can cause oophoritis (invasion of the ovaries), salpingitis (involvement of the fallopian tubes), parametritis, peritonitis and septicaemia.2 In 2017, the WHO enabled the establishment of a consensus definition for maternal sepsis, which is characterised by organ dysfunction caused by an infection during pregnancy, childbirth, postabortion or the postpartum period.3 A range of endogenous or foreign pathogens, including Escherichia coli, Clostridium tetani, Clostridium welchii, Chlamydia, Klebsiella, Staphylococcus aureus, Streptococci, Staphylococci and Gonococci, can result in PS.4
Globally, obstetric infections are considered to be the second leading cause of maternal mortality after postpartum haemorrhage (PPH), accounting for 10.7% of all deaths. The majority of these deaths occur in low-income and middle-income countries, with high-income countries (HICs) accounting for 4.7% of all deaths.3 At least 75 000 maternal deaths occur annually due to PS, which accounts for 2.1% of maternal deaths in HICs and 11.6% of maternal deaths in Asia, 9.7% in Africa and 7.7% in Latin America and the Caribbean.5
Roughly 1 in 1000 postpartum women may experience a serious infection; of these, 3%–4% will develop septic shock, and half will advance to sepsis with organ failure. For each sepsis-related parturient death, there are fifty severe cases of maternal morbidity, resulting in pelvic adhesions, chronic pelvic pain and secondary infertility.6 In Africa, PS ranks anywhere from first to fourth among the primary causes of maternal deaths.7 In those countries, PS women end up with septicemia (42.4%), pelvic peritonitis (17.6%), pelvic abscess (15.3%), endotoxin shock (9.4%), deep vein thrombosis (8.2%) and renal failure (7.1%).8
In Pakistan and India, 0.7% and 0.2% of postpartum mothers, respectively, suffer from PS.9 10 In Tanzania, Nigeria, Cameroon, Uganda, Ghana and Kenya, PS affects 11.5%, 10.0%, 17.9%, 39.9%, 9.1% and 12.2% of postpartum women, respectively.11–15 In Ethiopia, PS prevalence was reported to vary from 5.7% to 17.2%,1 16 with a 14.8% pooled prevalence.17 Following haemorrhage and hypertensive disorders of pregnancy, PS was the third most common direct cause of maternal mortality in Ethiopia.18 Furthermore, 51% of postpartum morbidity in Ethiopia was attributed to PS.19
Vaginal examinations more than five times during delivery, prolonged labour, prolonged premature rupture of the membranes, chorioamnionitis, PPH, manual removal of the placenta, caesarean sections, HIV/AIDS, extremes of maternal age, obesity and parity were all found to be contributing factors for the development of PS during childbirth and the postpartum period.1 12 15 16 20
Although maternal mortality in Ethiopia has declined, the rate of death is still high21 and PS has been a problem up to now.1 16 17 In Ethiopia, PS is inconsistent in terms of contributing factors.16 17 20 22 In addition, there is a paucity of case–control studies investigating the causes of PS in Ethiopia. Moreover, to the best of the authors’ knowledge, no research has been conducted in this study area. Therefore, this study aimed to assess determinants of PS among postpartum women attending East Shoa Zone public hospitals in Central Ethiopia.
Methods
Study setting and period
This study was conducted in East Shoa Zone public hospitals, Oromia region, Ethiopia, from 19 June 2023 to 4 September 2023. East Shoa Zone is an administrative subregion in Oromia, Ethiopia, located 100 km from the capital city, Addis Ababa. There were six public hospitals in East Shoa Zone that offer a range of healthcare services to an estimated 2.1 million people, namely Adama Hospital, Bishoftu Hospital, Batu Hospital, Olenchiti Hospital, Mojo Hospital and Meki Hospital. Covering 8370.90 km2 and a population density of 254.0, the East Shoa Zone comprises 11 districts and 2 town administrations.23 On average, there were 12 250 deliveries annually across these institutions.
Study design
A facility-based prospective case–control study was employed.
Population
Source population
All postpartum mothers attending public hospitals in East Shoa Zone were the source population.
Study population
Selected postpartum mothers attending public hospitals in East Shoa Zone during the study period were the study population.
Eligibility criteria
Inclusion and exclusion criteria for cases
Postpartum mothers with the diagnosis of PS attending maternity wards at public hospitals in East Shoa Zone during the study period were the cases for the current study. Those mothers who had incomplete cards, could not communicate or were experiencing mental health issues during the data collection period were excluded from the study.
Inclusion and exclusion criteria for controls
Postpartum mothers without PS attending the EPI unit at 42 days of postpartum in public hospitals in East Shoa Zone during the study period were the controls. Postpartum mothers who had already been admitted to another healthcare facility within the previous 42 days for the management of sepsis were excluded.
Sample size determination
A number of variables identified from different previous literatures were considered for the sample size calculation. Caesarean delivery was employed as a determinant in this study, resulting in a larger sample size based on a study from West Shoa, Ethiopia.20 The sample size was determined using Epi Info V.7.2.5 statistical software for an unmatched case–control study. During the calculation, the following assumptions were made: 95% CI 80% power (1−β), ratio of the control to case 4:1, the proportion of cases with caesarean delivery (35.8%), proportion of control mothers with caesarean delivery (20.7%) and adjusted OR (AOR) (3.85). Consequently, the largest sample size (498), consisting of 100 cases and 398 controls, was enrolled after accounting for a 10% non-response rate.
Sampling technique and procedure
All six public hospitals in the East Shoa Zone were included in the study. The sample size was proportionally allocated to each hospital based on the number of postnatal women who visited the hospitals in the past 2 months. A total of 956 postnatal women visited the hospitals: 128 women with PS and 828 women without PS. All medical charts were reviewed for completeness and to verify PS among study participants attending postnatal and EPI units. All cases were consecutively selected from postpartum mothers with PS admitted to the maternity ward. The first control was selected by the lottery method, and the subsequent controls were selected by a systematic sampling technique at every second interval (828/398) for each hospital. Each control was selected from the same hospitals for each case with a one-to-four ratio of case to control until the required sample size was achieved (figure 1).
Schematic presentation of sampling procedure for the determinants of puerperal sepsis (PS) among study participants at public hospitals in East Shoa, Ethiopia, 2023. Based on the number of postpartum women each hospital managed in the preceding 2 months, proportionate allocations were made to each hospital. Cases were added one after the other while controls were chosen at every two intervals. For every case, four controls—women without PS—were thus added to the sample.
Study variables
Dependent variable
Puerperal sepsis
Independent variables
The independent variables explored in this study were adapted with some adjustments after thoroughly reviewing related literature.1 15 22 The sociodemographic variables explored include age, residence, educational level, marital status, occupational status and monthly income. Birth interval, antenatal care (ANC), birth attendant, mode of delivery, place of delivery, antepartum haemorrhage, preterm, meconium-stained amniotic fluid (MSAF), gestational diabetes mellitus (GDM), PPH, pre-eclampsia, obstructed labour, parity, prolonged labour, labour induction, prolonged rupture of membrane, chorioamnionitis, number of vaginal examinations, episiotomy and cervical cerclage were among the obstetric and reproductive health variables that were investigated in this study. Maternal medical health-related variables included anaemia, hypertension and the HIV.
Operational and term definitions
Puerperal sepsis
Puerperal sepsis is genital tract infections occurring at any time between the rupture of membranes or labour and the 42 day post partum in which two or more of the following are present: pelvic pains, fever (ie, oral temperature 38.5°C or higher on any occasion), abnormal vaginal discharge (example pus), abnormal smell or foul odour of discharge, delay in the rate of involution of the uterus (less than 2 cm per day during the first 8 days).22
Cases
All postpartum mothers clearly recognised for the presence of PS by physician or other health professionals based on WHO criteria, physical examination and laboratory result.
Controls
All postpartum mothers clearly recognised for the absence of PS by reviewing the medical chart.
Complete medical chart
Complete medical chart for this study was participant’s medical chart that, hold clearly/fully documented obstetric history, delivery history and confirmed PS.
Obstructed labour
Obstructed labour is failure of the fetal presenting part to descent in the birth canal due to mechanical reasons, despite having adequate uterine contraction.24
Chronic hypertension
When postpartum women claimed or documented that she was ever diagnosed or treated for hypertension at least once before 20 weeks of pregnancy.25
Mid-upper arm circumference
Measurement of mid-upper arm circumference (MUAC) less than 21 cm by tape metre is considered malnutrition.8
Prolonged premature rupture of membrane
In which more than 24 hours has passed between the rapture of membrane and onset of labour.1
Gestational diabetes mellitus
Pregnant women when their fasting plasma glucose is ≥126 mg/dL, 2 hours plasma glucose is ≥200 mg/dL after taking 75 g oral glucose and random plasma glucose is ≥200 mg/dL with the presence of symptoms of diabetes mellitus.15
Diabetes mellitus
Diabetes mellitus is chronic high glucose levels in the blood as a result of the incapability of beta cells (β cells) in the pancreas to produce adequate insulin or ineffective insulin utilisation by cells in the body.26
Data collection procedures and tools
The data were collected through face-to-face interviews using a structured questionnaire adapted from previous studies.1 15 22 27 The medical chart was used to obtain additional information that could not be acquired by interview. For every individual, data were collected regarding their medical history, sociodemographics, obstetric and reproductive health traits, and aspects connected to the healthcare system. The malnutrition status of the women was measured by MUAC using a tape metre. Through a review of the women’s medical records, it was ascertained whether the women had pre-eclampsia, antepartum haemorrhage, PPH, placenta previa, anaemia, diabetes mellitus and hypertension.
The interview and data extraction from the medical chart were conducted after the study participant provided informed written consent. The interviews for cases were held after the enrolled mother’s health from PS improved and they were capable of responding to interview questions. The data were collected by 12 BSc midwives, and the data collection process was supervised by 6 masters of public health professionals.
Data quality control
The questionnaire was prepared in English and translated into the local languages (Afaan-Oromo and Amharic) by experts in the field. To ensure consistency, the questionnaires were translated back into English by another individual. A pretest was done on 5% of the total sample size before actual data collection at Shashamane Hospital to see the appropriateness of the tool. The necessary amendment was made following the result of the pretest. Training for a 1-day duration was given on ethical issues, the content and objectives of the study, and interview techniques for data collectors and supervisors in each hospital. The collected data were assessed by the lead investigators and supervisors to ensure clarity and completeness. The accuracy and consistency of the collected data were verified before data entry.
Data management and analysis
The collected data were coded and entered into Epi Data V.3.1 and then exported to SPSS V.25. After that, the data were cleaned, recoded, categorised and analysed using SPSS. Categorical variables were expressed as frequencies and percentages. Continuous variables were presented by the median with an IQR for not normally distributed variables. Cross-tabulations of independent variables were performed with the dependent variable.
Univariable binary logistic regression analysis was done to identify candidate variables for multivariable logistic regression. Those variables with a p≤0.20 in the univariable logistic regression models were taken into account in the multivariable logistic regression model. In multivariable logistic regression analysis, the stepwise backward variable elimination technique was performed to obtain the final reduced model, controlling for the confounding effects of other variables. Hosmer and Lemeshow goodness-of-fit showed that the model is a good fit (p=0.384). An OR with a corresponding 95% CI was reported as the measure of the strength of association for variables with p values of 0.05 or less in the multivariable logistic regression model. The result was presented through texts and tables.
Patient and public involvement
Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Results
Sociodemographic characteristics
The study included 495 postpartum women in total (100 cases and 395 controls), yielding a 99.4% response rate. 59% of the cases and 27.1% of the controls were older than 35 years. The age of respondents ranged from 16 to 49 with a median age of 35 (IQR: ±8) for cases and ranged from 16–50 with a median age of 31 (IQR: ±7) for controls. Urban dwellers comprised 31% of the cases and 65.6% of the controls. 30% of cases and 37% of controls were housewives, whereas 71 cases (71%) and 260 controls (65.8%) were married. 50% of the patients had never attended school, whereas 110 controls (or 27.9%) had completed at least secondary school. Of the spouses in the control group, about 202 (51.1%) had a higher education. 43% of the mothers who suffered from PS earned less than 1500 EB per month (table 1).
Sociodemographic characteristics of postpartum women attending East Shoa Zone public hospitals, Central Ethiopia, 2023 (n=495)
Obstetrics and reproductive health-related factors
Among the participants, 61 (61%) cases and 210 (53.2%) controls were multipara. The birth intervals of 60 (60%) cases and 99 (25.1%) controls were less than 2 years. 98.8% of the participants (489 cases and controls) had never undergone a cervical cerclage during their current pregnancy. Regarding the most recent delivery, 107 (27.1%) of the controls and 66 (66%) of the cases were referred from different healthcare facilities. In 121 (30.9%) controls and 71 (71%) cases, the membrane ruptured at least 24 hours before the onset of labour.
Regarding labour duration, 102 (25.6%) of the controls and 49 (49%) of the cases had labour that lasted 25 hours or more. More than half (69%) of cases and 118 (29.9%) of controls had manual removal of the placenta. In the current pregnancy, 37 cases (37%) and 56 controls (14.2%) had placenta previa. About 38% of mothers with PS and 37.5% of mothers without PS gave birth via caesarean section. Among all study participants, 72% of cases and 30.1% of controls experienced PPH, and 46% of cases and 18.9% of controls had five or more vaginal examinations (table 2). Obstetrics and reproductive health-related factors of postpartum women attending East Shoa Zone public hospitals, Central Ethiopia, 2023 (n=495)).
Obstetrics and reproductive health-related factors of postpartum women attending East Shoa Zone public hospitals, Central Ethiopia, 2023 (n=495)
Medical history and healthcare system-related factors
Among the study participants, 43% of cases and 74.9% of controls received four or more ANC follow-ups. Anaemia affected 52% of cases and 8.6% of controls. Just 4.8% of research participants—7% of cases and 4.3% of controls—had hypertension, and 9.7%—14% of cases and 8.6% of controls—had diabetes mellitus. About 11% of cases and 6% of controls had HIV. Malnutrition affected about 11% of cases and 6% of controls (table 3). Medical history and healthcare system-related factors of postpartum women attending East Shoa Zone public hospitals, Central Ethiopia, 2023 (n=495)).
Medical history and healthcare system-related factors of postpartum women attending East Shoa Zone public hospitals, Central Ethiopia, 2023 (n=495)
Determinants of PS
In univariable binary logistic regression analysis, age, residence, mother’s and husband’s educational levels, household monthly income, parity, birth interval, preterm delivery, twin delivery, referral status, MSAF, birth attendant, mode of delivery, mode of placenta delivery, duration of labour, duration of membrane rupture, number of per-vaginal (PV) examinations, retained placenta, abruption placenta, placenta previa, PPH, GDM, number of ANC, anaemia, obstructed labour and MUAC were significantly associated with the PS at a p≤0.20.
In multivariable logistic regressions, the stepwise backward variable elimination technique was conducted to show the determinants of PS, controlling for the confounding effects of other variables. The result of multivariable logistic regression indicated that parity is an independent determinant of PS at a p<0.05. Accordingly, the odds of developing PS were 2.54 times higher among multiparous women as compared with primiparous women (AOR 2.54; 95% CI 1.17 to 5.50). Mothers who experienced obstructed labour had 2.76 times higher odds of PS than mothers who did not (AOR 2.76; 95% CI 1.17 to 6.52).
Women who experienced PPH had three times increased odds of PS compared with women who had not had PPH (AOR 3.17; 95% CI 1.28 to 7.87). The odds of developing PS were 2.27 times higher in women who had placenta previa as compared with their counterparts (AOR 2.27; 95% CI 1.11 to 4.67). Mothers who had GDM had 3.26 times higher odds of PS than those without this condition (AOR 3.26; 95% CI 1.22 to 8.74).
According to this study, the odds of developing PS were 2.19 times higher in mothers who underwent five or more vaginal examinations than those who underwent fewer than five PV examination (AOR 2.19; 95% CI 1.05 to 4.54). Furthermore, women who had anaemia had six times higher odds of PS than mothers without anaemia (AOR 6.05; 95% CI 2.57 to 14.26). The findings of this study also showed that malnourished mothers had fourfold higher odds of developing PS than non-malnourished mothers (AOR 4.32; 95% CI 1.96 to 10.01) (table 4). Multivariable binary logistic regression analysis on determinants of PS among postpartum women attending East Shoa Zone public hospitals, Central Ethiopia, 2023 (n=495)).
Multivariable binary logistic regression analysis on determinants of puerperal sepsis among postpartum women attending East Shoa Zone public hospitals, Central Ethiopia, 2023 (n=495)
Discussion
This study aimed to identify determinants of PS among postpartum women attending East Shoa Zone public hospitals in Central Ethiopia, 2023. Accordingly, the findings of this study revealed that multiparity, placenta previa, PPH, obstructed labour, GDM, undernourishment, anaemia and five or more PV examinations during labour were the statistically significant determinants of PS.
This study showed that multiparous women had higher odds of developing PS as compared with primiparous women. This finding is in agreement with the findings of studies done in Ethiopia16 17 and Sudan.28 This could be due to the fact that multiparous women may be less inclined to seek medical attention promptly for symptoms of infection or sepsis due to having experienced childbirth before and assuming symptoms are normal. Another possibility is that certain obstetrical complications, such as retained placenta, PPH and uterine rupture, may increase with increasing parity. These complications raise the risk of PS because they require more frequent manipulations of the mother’s internal reproductive tract.17
This study revealed that obstructed labour was a significant determinant of PS. Women with obstructed labour have 2.76 times higher odds of developing PS compared with their counterparts. Studies carried out in Nigeria29 and Ethiopia24 30 have provided evidence in favour of this conclusion, showing that PS frequently occurs after obstructed childbirth. Mothers who experience an obstruction during birth are more likely to experience multiple vaginal exams, prolonged labour, a delay between amniotic sac rupture and delivery, PPH, non-scheduled caesarean delivery, uterine rupture and prolonged hospital stay—all of which increase the risk of infection.
The findings of this study demonstrated that women who experienced PPH had higher odds of developing PS. This outcome was in line with research done in Canada,31 the USA,32 India33 and Tanzania.11 It is possible for germs from the outside environment to enter the genital canal or for them to rise from the lower genital tract as a result of the repeated manipulations performed on the genital system to remove retained tissues, repair cervical rips or stop the bleeding in PPH. Moreover, the resulting anaemia could promote the growth of an infection.
In the current study, women with placenta previa were shown to have significantly increased odds of getting PS. Studies from China,34 35 India36 and Ethiopia37 all support this finding. The reason is that the placenta site in women with placenta previa may bleed uncontrollably after the placenta is removed since the smooth muscle in the lower uterine segment is not as contractile as the upper segment. Because of the significant PPH, the mother will become anaemic, which raises the risk of PS. Moreover, repeatedly manipulating the genital canal in an attempt to halt the bleeding could increase the risk of infection.
It was found that GDM was a statistically significant predictor of the development of PS. The results of prior investigations support this argument.15 31 38 39 Women with GDM have a 1.2-fold increased risk of PS, according to nationwide research conducted in Canada.31 A study conducted in southern Ethiopia showed that women who experienced GDM had notably greater odds of PS than women who had not experienced GDM.15
It is plausible that diabetic women are more susceptible to PS because high blood sugar is known to compromise the immune system’s ability to halt the spread of invading pathogens.26 In addition, mothers with diabetes frequently undergo difficult and invasive vaginal births due to shoulder dystocia or macrosomia, which calls for repeated genital tract manipulations, including incisions, raising the risk of infection.
This study found a twofold increase in the odds of PS in women who underwent five or more vaginal examinations during labour and delivery, compared with those who underwent fewer procedures. This finding is well supported by prior studies around the world.15 17 20 22 This frequent and needless manipulation of the vaginal canal may be the factor responsible for PS because it may permit the introduction of external germs, the ascent of bacteria from the lower genital tract and the disruption of normal flora.
The results of this study also demonstrated a strong association between anaemia and PS. This finding is consistent with studies conducted globally.11 17 25 27 31 33 40 41 A Canadian study discovered a strong correlation between maternal anaemia and an increased risk of sepsis. A strong association was found in a Swedish retrospective cohort study between anaemia resulting from acute blood loss and maternal sepsis. An Ethiopian meta-analysis investigation found that anaemic mothers had 5.68-fold higher odds of PS compared with normal moms. A possible explanation for this might be that iron deficiency impairs the immune system, making a person more vulnerable to infection.
Malnourished mothers had fourfold increased odds of developing PS compared with non-malnourished mothers. This outcome was consistent with a Bangladeshi study.42 This might be the result of undernutrition impairing the immune system’s capacity to fight off invasive microbes. In addition, malnourished mothers are more likely to suffer from anaemia, which further raises the possibility of postpartum sepsis.
Strengths and limitations of study
The study was prospective and assessed risk factors using a more logically sound study design. Obstetric factors not measured in earlier Ethiopian studies were included in this study, including preeclampsia, birth interval, cervical cerclage, antepartum haemorrhage and PPH. The multicentric approach of the study may have enhanced the generalisability of the findings. The controls were added to the study at the end of the 42-day postpartum period in order to minimise selection and misclassification bias.
Besides its strengths, this study has certain limitations. First, the study had to rely on hospital cases and controls. Recall bias might have been introduced when some factors—such as the number of vaginal exams and the length of the delivery—were gathered through interviews with the women because of their absence in the medical charts. Ultimately, the study’s design precluded it from examining certain drivers of sepsis, such as those associated with healthcare providers and health facilities.
Implications for policy, practice and research
Policy initiatives should emphasise the education and training of healthcare professionals in the areas of primary avoidance of high-risk situations, early identification of at-risk patients and enhanced clinical management of PS. Obstetric care providers must provide comprehensive health education regarding nutrition during pregnancy and postnatal periods and the importance of iron supplements.
Future researchers should focus on conducting population-based studies, as the burden of community-based sepsis is greater and has gone unnoticed. Large-scale longitudinal investigations are advised to ascertain how well such factors are associated with PS, the clinical outcome and the impact of PS.
Conclusion
This study found that GDM, anaemia, undernourishment, placenta previa, obstructed labour, PPH and five or more PV examinations during labour were the determinants of PS. Therefore, it is recommended that obstetric care providers strictly adhere to guidelines on the number of vaginal exams that should be performed throughout labour and that they perform these exams using the appropriate infection-prevention techniques. It is advised that healthcare professionals intensify early screening and management of obstetric complications, including placenta previa, PPH, GDM and obstructed labour.
Data availability statement
Data are available on reasonable request. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
The studies involving human participants were reviewed and approved by the Ethical Review Board of Salale University with reference number IRB/878/14. Written informed consent to participate in this study was obtained from each study participant after explaining the purpose, procedure, benefits, duration and any possible risks of the study using the local language. The participant’s right to discontinue or leave the study was also secured. This study was performed in line with the principles of the Declaration of Helsinki. The entire information collected from the study participants was handled confidentially by omitting their identifiers.
Acknowledgments
The authors are indebted to the Salale University College of Health Science for the approval of the ethical clearance. They are also thankful to the East Shoa Zonal Health Office and the public hospitals in East Shoa Zone for their permission to carry out this study in the hospitals. Finally, they would like to thank the study participants and data collectors for their cooperation throughout the study period.
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