Frequency and management of maternal infection in health facilities in 52 countries (GLOSS): a 1-week inception cohort study
Open accessAbstract
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.
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Physiological changes in pregnancy (temperature rise 0.39-0.78°C, heart rate increase 10-15 times/min during rest in late pregnancy, blood pressure U-shaped change, white blood cell count increase) overlap with early manifestations of infection, making early identification difficult.
“which overlaps with early manifestations of infection, making early identification difficult”
From Clinical and Pathogenic Characteristics of 45 Cases of Bloodstream Infection in Obstetrics: A Clinical Analysis (2026) · cites this paper as [2]
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Experimental — accuracy not yet measuredThe global burden of maternal deaths is highest in Sub-Saharan Africa.
“The global burden of maternal deaths is highest in Sub-Saharan Africa (SSA) [4, 5].”
From The aetiology and antimicrobial resistance of bacterial maternal infections in Sub-Saharan Africa—a systematic review and meta-analysis (2024) · cites this paper as [4]
The Introduction (page unavailable) discusses maternal deaths due to infection and compares low- and middle-income countries with high-income countries. The Results (page unavailable) also group outcomes by country income, but neither passage compares maternal deaths across world regions. Searches for sub-Saharan Africa and regional maternal mortality found no passage establishing that its burden is the highest. (LLM, conf=0.76)
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A Multicomponent Intervention to Improve Maternal Infection Outcomes
Lissauer, D. M., Gadama, L. A., Waitt, C. J., Whyte, S., Burnside, G., Anilkumar, A., Makuluni, R., Okwaro, P., Yang, L., Waitt, P. I., et al. (2025) · New England Journal of Medicine · doi:10.1056/nejmoa2512698 · Cited by 8 · see citing works
“3,14 Structured tools and bundles of care have been shown to improve recognition, timely treatment and outcomes for other obstetric emergencies such as postpartum hemorrhage, even in resource constrained health facilities.”
Self-citationPrevalence and factors associated with neonatal sepsis in Mali: a cross-sectional study
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Self-citationCaring for two in the ICU : Pharmacotherapy in the critically ill pregnant patient
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Self-citationEvaluation of the feasibility of the FAST-M maternal sepsis intervention in Pakistan: a protocol
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“More recent WHO estimates that were focused specifically on better understanding the contribution of maternal infection to adverse outcomes suggested that up to half of all maternal deaths were actually infection-related [9].”
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“One important aspect of this is maternal infections, which occur commonly during pregnancy and can require treatment with prescription drugs, or hospital admission in more severe cases (Collier et al. , 2009; WHO Global Maternal Sepsis Study Research Group, 2020).”
BackgroundAhmed, S. I., Rind, G. K., Sikandar, R., Raza, A., Khowaja, B. M. H., Parveen, F., Khan, S., Memon, N., Jahangir, A., Mirza, D. N., et al. (2023) · BMJ Open · doi:10.1136/bmjopen-2022-069135 · Cited by 7 · see citing works
Self-citationLet's get loud: Amplifying female voices in sepsis research
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Development of the Sepsis-Associated Adverse Outcomes in Pregnancy Score
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“Awareness among clinicians of sepsis might lead to early diagnosis and effective management of sepsis.(6,31) A long road lies ahead in this battle against maternal sepsis due to the ever-evolving and new data available.”
BackgroundReducing post‐cesarean sepsis: Current best practice in prevention and treatment
Lazzaro, A., Karandikar, G., Martins, M. L., Saidi, F., Aronoff, D. M., do Amaral, E. M. S., Boucoiran, I., Megh, M., Jacobsson, B., Lizcano, E. I. O., et al. (2025) · International Journal of Gynecology & Obstetrics · doi:10.1002/ijgo.70500 · Cited by 5 · see citing works
“11 Due to the significant maternal physical and psychological sequelae, the decision for peri-partum hysterectomy should ideally be made by a senior clinician after a multidisciplinary discussion.”
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“The reported prevalence of maternal sepsis varied widely with reported regions and definitions for sepsis [2, 3].”
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“[5] Not surprisingly, the data may imply that maternal and newborn deaths in low-and middle-income countries are high at an estimated 415 maternal deaths/100,000 live births, with a lifetime risk as high as 1 in 37 among girls aged 15”
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“Therefore, the prevention and emphasis on early diagnosis of sepsis is critical to enhance the management of maternal sepsis and has led to several “care bundles” being implemented in general wards [1].”
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“This issue has been highlighted by the GLOSS group, following their recent study, where they stressed the urgent need to improve early identification of maternal sepsis [5].”
BackgroundRecognising the burden of maternal infection worldwide.
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“Global estimates suggest that direct (obstetric) infections are the third most common cause of maternal mortality, representing 10·7% of maternal deaths, with the largest toll estimated in low- and middle-income countries (LMICs) at 10·7% compared with high-income countries at 4·7% [1, 3].”
BackgroundSelf-citationLucas, S., Knight, M., Lucas, N., & Rodger, A. (2021) · The Lancet · doi:10.1016/s0140-6736(21)01381-7 · Cited by 3 · see citing works
Self-citationSpezielle intensivmedizinische Krankheitsbilder der schwangeren Patientin
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“As many as 60% of maternal deaths occur after giving birth, and almost 50% of deaths during the postpartum period occur within the first 24 hours after giving birth (Bonet et al., 2020; Jung et al., 2024; Shah et al., 2024).”
Peritonitis following caesarean section in a low-resource setting
Onrust, M. R., Mtaya, G., Phiri, P., & Riches, J. (2024) · BMJ Case Reports · doi:10.1136/bcr-2024-260497 · Cited by 2 · see citing works
Sepsis in obstetric care for the emergency clinician: A review
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Ozarslan, N., Gaw, S., Cassidy, A., & Caughey, A. (2023) · Journal of Perinatology · doi:10.1038/s41372-023-01696-3 · Cited by 2 · see citing works
“According to the World Health Organization, the frequency of infection-related maternal deaths around the world is much greater than previously estimated [19].”
BackgroundHeemelaar, S., Agapitus, N., van den Akker, T., Stekelenburg, J., Mackenzie, S., Hugo-Hamman, C., & Auala, T. (2022) · Tropical medicine & international health · doi:10.1111/tmi.13804 · Cited by 2 · see citing works
Immunology of pregnancy and sepsis: shared and specific pathways guiding future precision care
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Incidence of maternal infection and its related outcomes in a public sector hospital in Pakistan
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Assessing patient-level risk factors for evidence-based early diagnosis of maternal sepsis
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“…Global Maternal Sepsis Study Research Group, in 2017, around 70 out of every 1,000 live births involved pregnant or recently pregnant women requiring hospital care due to maternal infections; also, infections were associated with over half of the intrahospital maternal deaths in the same year [7].”
Singh, S., Jain, N., Parihar, S. S., Singh, A. R., Bakshi, S., Kabirpanthi, V., & Singh, N. (2025) · BMC Pregnancy and Childbirth · doi:10.1186/s12884-025-07835-2 · Cited by 1
“Recent evidence suggest that post-caesarean section SSIs have much greater impact on maternal deaths, than previously believed [9], suggesting that settings with high maternal mortality likely to have high burden of SSI rate as well.”
Clinical characteristics associated with peripartum maternal bloodstream infection
Gao, X., Li, Y., Hou, S.-J., Fan, W.-J., Fang, L., Ni, S.-J., Yan, Y., Li, J., & Han, C. (2024) · Frontiers in Microbiology · doi:10.3389/fmicb.2024.1454907 · Cited by 1 · see citing works
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“Particularly during childbirth, the immune function of the body is greatly weakened, making postnatal mothers highly susceptible to infections by bacteria, viruses, and other pathogens [1–3].”
BackgroundFair Reinforcement Learning for Maternal Sepsis Treatment
Carey, S., McInerney, C., Lawton, T., Habli, I., Johnson, O., Fahel, L., Kotze, A., & de Kamps, M. (2022) · medRxiv · doi:10.1101/2022.08.09.22278582 · Cited by 1
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“…significant physical and emotional repercussions, which may be considered near miss events (32) , given that maternal sepsis is an avoidable cause of mortality for thousands of women each year (33) , and the quality of the care environment is presumed to be a mediating factor in its prevention.”
Maskay, G., & Ongan, L. P. (2026) · International Journal of Africa Nursing Sciences · doi:10.1016/j.ijans.2026.101186
Incidence and risk factors for postpartum infections: A Norwegian cohort study, 2012–2020
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Self-citation
- Authors
- Bonet, M., Brizuela, V., Abalos, E., Cuesta, C., Baguiya, A., Chamillard, M., Fawole, B., Knight, M., Kouanda, S., Lumbiganon, P., Nabhan, A., Nadisauskiene, R. J., Abdulkadir, A., Adanu, R. M., Aman, M. I., Arriaga Romero, W. E., Assarag, B., Bloemenkamp, K. W. M., Boobekova, A., Budianu, M. A., Cararach, V., Castro, R., Cebekhulu, S., Cecatti, J. G., Colmorn, L. B., Curteanu, A., Donati, S., Einda, H. M. T., El Deen, Y. S., El Kak, F., Elsheikh, M., Escobar-Vidarte, M. F., Espinoza, M. M., Estrada, M. E., Gadama, L. A., Goufodji, S. B., Hamid, S., Hernandez Munoz, R., Herrera Maldonado, N., Jayaratne, K., Kabylova, S., Kristufkova, A., Kumar, V., Lissauer, D., Mereci, W., Minkauskiene, M., Moreira, P., Munjanja, S., B. Osman, N., Ouedraogo, H. G., Perez, A. M., Pasquale, J., Puscasiu, L., Qureshi, Z., Recidoro, Z., C. Ribeiro-do-Valle, C., Rowel, D., Sangho, H., Shrestha, A. B., Siriwachirachai, T., Tebeu, P. M., Tin, K. N., Tuan, D. A., Tung, R., Vandenberghe, G., Yadamsuren, B., Yunusova, D., Zavaleta Pimentel, N., Noormal, B., Díaz, V., Leroy, C., Roelens, K., Agossou, M. C. U., Tshabu Aguemon, C., Apaza Peralta, P. S., Conde Altamirano, V., Batiene, V., Cisse, K., Cheang, K., Lam, P., Simo, E., Yakana, E. I., Carvajal, J., Fernández, P., Langhoff-Roos, J., Vélez, P., Sultan, A., Teklu, A. M., Worku, D., Govule, P., Noora Lwanga, C., Flores Aceituno, M. G., Bustillo, C., Lara, B., Suri, V., Trikha, S., Cetin, I., Personeni, C., Baimussanova, G., Sagyndykova, B., Gwako, G., Osoti, A., Asylbasheva, R., Seksenbaeva, D., Itani, S. E., Abou Malham, S., Ramašauskaitė, D., Chikhwaza, O., Malunga, E., Dembele, H., Sangho, H., Zerbo, F. E., Dávila Serapio, F., Islas Castañeda, J. I., Cauaus, T., Petrov, V., Khishgee, S., Lkhagvasuren, B.-E., Essolbi, A., Moulki, R., Jaze, Z., Mariano, A., Maung, T. M., Gurung, T., Shrestha, S., Rijken, M. J., Van Den Akker, T., Estrada, M. E., Pavón Gómez, N. J., Adesina, O., Aimakhu, C., Chaudhri, R., Khan, M. A., Huatuco Hernández, M. D. P., Andal, M. L., Martin, C. P., Diouf, L., Guirassy, D., Borovsky, M., Kovac, L., Cornelissen, L., Soma-Pillay, P., López, M., Vidal Benedé, M. J., Jayakody, H., Elsheikh, M., Nabag, W., Omer, S., Tsoy, V., Uzakova, U., Tangsiriwatthana, T., Dunlop, C., Roman, J., Vitureira, G., Truong, L. N., Hanh, N. T. X., Madziyire, M., Magwali, T., Bartlett, L., Bellissimo-Rodrigues, F., Jacob, S. T., Shakoor, S., Yunis, K., Campodónico, L., Gamerro, H., Giordano, D., Althabe, F., Gülmezoglu, A. M., & Souza, J. P.
- Affiliations
- World Health Organization (CH)
- Corresponding author
- Bonet, Mercedes
- ORCID
- Bonet, Mercedes
- Brizuela, Vanessa
- Abalos, Edgardo
- Cuesta, Cristina
- Baguiya, Adama
- Fawole, Bukola
- Knight, Marian
- Lumbiganon, Pisake
- Nabhan, Ashraf
- Assarag, Bouchra
- Bloemenkamp, Kitty W.M.
- Castro, Rigoberto
- Cebekhulu, Sylvia
- Cecatti, José Guilherme
- Colmorn, Lotte Berdiin
- Curteanu, Ala
- Donati, Serena
- Gadama, Luis Aaron
- Hamid, Saima
- Jayaratne, Kapila
- Kabylova, Saule
- Kumar, Vijay
- Lissauer, David
- Moreira, Philippe
- Pasquale, Julia
- Qureshi, Zahida
- Rowel, Dhammica
- Shrestha, Amir Babu
- Tebeu, Pierre Marie
- Tin, Khaing Nwe
- Vandenberghe, Griet
- Díaz, Virginia
- Leroy, Charlotte
- Roelens, Kristien
- Cheang, Kannitha
- Vélez, Paola
- Worku, Dawit
- Govule, Philip
- Suri, Vanita
- Trikha, Sonia
- Cetin, Irene
- Gwako, George
- Osoti, Alfred
- Ramašauskaitė, Diana
- Maung, Thae Maung
- Shrestha, Sangeeta
- Rijken, Marcus J.
- Adesina, Olubukola
- Chaudhri, Rizwana
- Khan, M. Adnan
- Cornelissen, Laura
- López, Marta
- Jayakody, Hemali
- Dunlop, Catherine
- Vitureira, Gerardo
- Madziyire, Mugove
- Bartlett, Linda
- Jacob, Shevin T.
- Shakoor, Sadia
- Yunis, Khalid
- Althabe, Fernando
- Souza, João Paulo
- Venue
- The Lancet Global Health
- Publisher
- Elsevier BV
- Published
- 2020-05
- Volume
- 8
- Issue
- 5
- Pages
- e661-e671
- ISSN
- 2214-109X (ISSN-L)
- PMC
- PMC7196885
- OpenAlex
- W3020272230
- Cited by
- 176
- References
- 32
- Citations by year
- 2026: 22 · 2025: 27 · 2024: 40 · 2023: 19 · 2022: 24 · 2021: 30 · 2020: 13
- FWCI
- 16.12
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- The Lancet Global Health (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Pure Amsterdam UMC (publishedVersion, other-oa)
- LSTM Online Archive (Liverpool School of Tropical Medicine) (acceptedVersion)
- Ghent University Academic Bibliography (Ghent University) (submittedVersion, cc-by)
- Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Utrecht University Repository (Utrecht University) (submittedVersion, other-oa)
- Conicet (submittedVersion, cc-by)
- Funders
- World Bank Group (A65787)
- World Health Organization
- United States Agency for International Development (GHA-G-00-09-00003)
- UNICEF
- United Nations Population Fund
- Merck Sharp and Dohme
- St. Joseph Health Ministries
- United Nations Development Programme
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Neonatal and Maternal Infections
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Global Maternal and Child Health
- Health Sciences › Medicine › Epidemiology › Sepsis Diagnosis and Treatment
- Keywords
- maternal infection, maternal sepsis, severe maternal morbidity, maternal mortality, in-hospital mortality, antimicrobial use, vital signs recording, low- and middle-income countries, obstetric care, abortion services, postpartum infection, post-abortion complications, infection severity, country income groups
- MeSH terms
- Adult, Female, Health Facilities, Humans, Pregnancy, Pregnancy Complications, Infectious, Global Health, Cohort Studies, Incidence
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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