New research from the Global Maternal Sepsis Study (GLOSS), a major WHO/HRP initiative, shows that infection has a much larger impact on global maternal mortality and morbidity than previously thought.
The results from GLOSS, published in The Lancet Global Health, are the first to provide data on frequency of maternal infections and sepsis across the pregnancy and post-pregnancy period, in a large number of health facilities around the world.
Around 11 women per 1000 live births had an infection which resulted in or contributed to what is known as a severe maternal outcome – either they died or nearly died – during their hospitalization.
Urgent improvement is needed to manage this life-threatening risk faced by all pregnant and recently pregnant women, wherever they are in the world.
What is maternal sepsis and how does it lead to maternal death?
Maternal sepsis is a life-threatening condition that arises when the body’s response to infection causes injury to its own tissues and organs during pregnancy, child-birth, post-abortion or the postpartum period.
The latest global estimates place sepsis due to obstetric infections as the third most common cause of maternal mortality. However, this only includes infections as a direct result of pregnancy, such as endometritis or post-caesarean wound infections.
Few previous studies include post-abortion infections. Neither do they address indirect infections such as respiratory and meningitis, which are aggravated by pregnancy but not directly caused by it.
A better understanding of maternal infection
GLOSS was a massive facility-based data collection effort led by WHO, accompanied by a ‘STOP SEPSIS!’ campaign to increase awareness among healthcare providers.
The study gathered data on women who were admitted with suspected or confirmed infection during pregnancy or post-pregnancy over a one-week period in 2017. More than 2800 women participated in the study in 52 countries.
GLOSS included healthcare facilities that care for women during pregnancy, childbirth or at the end of pregnancy, as well as facilities without maternity service but where women could be hospitalized during or after pregnancy, and data on infections which are not usually recorded as maternal sepsis, including post-abortion and indirect infections.
The result is a more complete understanding of the frequency and impact of maternal infections in health facilities.
GLOSS calls attention not only to the wider range of risks faced by pregnant women but also to the long period of time during which they are at risk.
Putting global numbers on maternal infection and sepsis
Overall, around 70 pregnant or recently-pregnant women per 1000 live births were found to have a maternal infection needing hospital management.
Across the study, 11 women with either direct or indirect infection per 1000 live births developed a severe maternal outcome, but in low- and middle-income countries up to 15 women per 1000 births were affected.
Infections were the underlying cause of most of the deaths recorded during the study, primarily post-abortion infection and indirect infections. Infections were also present in about a third of deaths attributed to other causes, such as postpartum haemorrhage.
This suggests that the contribution of infection to global maternal mortality and morbidity may be larger than current reports of maternal sepsis mortality suggest.
Preventing, identifying and treating maternal infection and sepsis
Some of the most common maternal infections found in the study, such as urinary tract infections, post-caesarean and post-abortion infections, are largely preventable and treatable.
GLOSS results suggest that current levels of monitoring and clinical care across health facilities are not enough to prevent, identify and treat levels of maternal infection effectively.
For instance, a complete set of vital signs was not reported for a third of the women in the study, on the day their infection was suspected or diagnosed. Delays in antimicrobial therapy were frequent.
GLOSS also shows marked differences across countries, with the highest burden in low- and middle-income countries, compared with high-income countries.
This may reflect the impact of broader health determinants in different country contexts. Challenges of overcrowding, limited access to water and sanitation and constraints to safe births by skilled birth attendants can reduce the ability of healthcare providers to manage the frequency and outcome of maternal infections.
An opportunity to implement evidence-based practice
GLOSS gives healthcare providers, policy-makers, and the public at large an opportunity: to mobilise around these data improve evidence-based practice, and save lives.
WHO has produced a number of resources which can support timely action to prevent, diagnose and treat maternal infection, as well as activities such as the upcoming SAVE LIVES: Clean Your Hands campaign on 5 May which celebrates the central role played by nurses and midwives in clean health care.
In addition, WHO will publish a global sepsis epidemiology report around the 73rd World Health Assembly (WHA) in May, as requested in the 2017 WHA Resolution on Improving the prevention, diagnosis and clinical managementof sepsis.
Understanding why and how infection affects women is essential for equipping healthcare providers with life-saving knowledge and enabling health care systems to bring down global maternal mortality and morbidity.