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Cited by 176Neonatal and Maternal InfectionsGlobal Maternal and Child HealthSepsis Diagnosis and Treatment

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

Open access
Bonet, Mercedes, Brizuela, Vanessa, Abalos, Edgardo, Cuesta, Cristina, Baguiya, Adama, Chamillard, Mónica, Fawole, Bukola, Knight, Marian, Kouanda, Seni, Lumbiganon, Pisake, Nabhan, Ashraf, Nadisauskiene, Ruta J, Abdulkadir, Abdulfetah, Adanu, Richard MK, Aman, Mohammad Iqbal, Arriaga Romero, William E., Assarag, Bouchra, Bloemenkamp, Kitty W.M., Boobekova, Aigul, Budianu, Mihaela A., Cararach, Vicenç, Castro, Rigoberto, Cebekhulu, Sylvia, Cecatti, José Guilherme, Colmorn, Lotte Berdiin, Curteanu, Ala, Donati, Serena, Einda, Hla Mya Thway, El Deen, Yasser Salah, El Kak, Faysal, Elsheikh, Mohamed, Escobar-Vidarte, Maria F, Espinoza, Marisa Mabel, Estrada, María Ester, Gadama, Luis Aaron, Goufodji, Sourou B, Hamid, Saima, Hernandez Munoz, Rosalinda, Herrera Maldonado, Nazarea, Jayaratne, Kapila, Kabylova, Saule, Kristufkova, Alexandra, Kumar, Vijay, Lissauer, David, Mereci, Wilson, Minkauskiene, Meile, Moreira, Philippe, Munjanja, Stephen, B. Osman, Nafissa, Ouedraogo, Henri Gautier, Perez, Aquilino M., Pasquale, Julia, Puscasiu, Lucian, Qureshi, Zahida, Recidoro, Zenaida, C. Ribeiro-do-Valle, Carolina, Rowel, Dhammica, Sangho, Hamadoun, Shrestha, Amir Babu, Siriwachirachai, Thitiporn, Tebeu, Pierre Marie, Tin, Khaing Nwe, Tuan, Dinh Anh, Tung, Rathavy, Vandenberghe, Griet, Yadamsuren, Buyanjargal, Yunusova, Dilrabo, Zavaleta Pimentel, Nelly, Noormal, Bashir, Díaz, Virginia, Leroy, Charlotte, Roelens, Kristien, Agossou, M. Christian Urlyss, Tshabu Aguemon, Christiane, Apaza Peralta, Patricia Soledad, Conde Altamirano, Víctor, Batiene, Vincent, Cisse, Kadari, Cheang, Kannitha, Lam, Phirun, Simo, Elie, Yakana, Emah Irene, Carvajal, Javier, Fernández, Paula, Langhoff-Roos, Jens, Vélez, Paola, Sultan, Alaa, Teklu, Alula M., Worku, Dawit, Govule, Philip, Noora Lwanga, Charles, Flores Aceituno, María Guadalupe, Bustillo, Carolina, Lara, Bredy, Suri, Vanita, Trikha, Sonia, Cetin, Irene, Personeni, Carlo, Baimussanova, Guldana, Sagyndykova, Balgyn, Gwako, George, Osoti, Alfred, Asylbasheva, Raisa, Seksenbaeva, Damira, Itani, Saad Eddine, Abou Malham, Sabina, Ramašauskaitė, Diana, Chikhwaza, Owen, Malunga, Eddie, Dembele, Haoua, Sangho, Hamadoun, Zerbo, Fanta Eliane, Dávila Serapio, Filiberto, Islas Castañeda, Juan I., Cauaus, Tatiana, Petrov, Victor, Khishgee, Seded, Lkhagvasuren, Bat-Erdene, Essolbi, Amina, Moulki, Rachid, Jaze, Zara, Mariano, Arlete, Maung, Thae Maung, Gurung, Tara, Shrestha, Sangeeta, Rijken, Marcus J., Van Den Akker, Thomas, Estrada, María Esther, Pavón Gómez, Néstor J., Adesina, Olubukola, Aimakhu, Chris, Chaudhri, Rizwana, Khan, M. Adnan, Huatuco Hernández, María del Pilar, Andal, Maria Lu, Martin, Carolina Paula, Diouf, Léopold, Guirassy, Dembo, Borovsky, Miroslav, Kovac, Ladislav, Cornelissen, Laura, Soma-Pillay, Priya, López, Marta, Vidal Benedé, María José, Jayakody, Hemali, Elsheikh, Mohamed, Nabag, Wisal, Omer, Sara, Tsoy, Victoria, Uzakova, Urunbish, Tangsiriwatthana, Thumwadee, Dunlop, Catherine, Roman, Jhon, Vitureira, Gerardo, Truong, Luong Ngoc, Hanh, Nghiem Thi Xuan, Madziyire, Mugove, Magwali, Thulani, Bartlett, Linda, Bellissimo-Rodrigues, Fernando, Jacob, Shevin T., Shakoor, Sadia, Yunis, Khalid, Campodónico, Liana, Gamerro, Hugo, Giordano, Daniel, Althabe, Fernando, Gülmezoglu, A. Metin, Souza, João Paulo·2020·The Lancet Global Health
DOI 10.1016/s2214-109x(20)30109-1PMC PMC7196885
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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.

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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 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.CC BY · PubMed Central
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.
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.CC BY · PubMed Central

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  1. Cebekhulu, 2018, Too little, too late: the recurrent theme in maternal deaths due to sepsis, O&G Forum, 28, 9

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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
Venue
The Lancet Global Health
Publisher
Elsevier BV
Published
2020-05
Volume
8
Issue
5
Pages
e661-e671
ISSN
2214-109X (ISSN-L)
DOI
10.1016/s2214-109x(20)30109-1
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
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 › Pediatrics, Perinatology and Child Health › Neonatal and Maternal Infections
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Global Maternal and Child Health
  • Health Sciences › Medicine › Critical Care and Intensive Care Medicine › 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

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