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Puerperal Sepsis Global Overview Global Forum on Bacterial Infections & Antibiotic Resistance New Delhi, October 2011
Jeffrey Smith, MD, MPH Maternal Health Director
Seth Rosenblatt, MPH Sr. Program Officer MCHIP / Jhpiego
Causes of Maternal Death
§ Hemorrhage § Sepsis § Eclampsia § Abortion § Obstructed labor § HIV
§ 75% of maternal death due to 5 main causes
Khan LANCET 2007
2
Contributing Factors and Prevention
Contributing Factors § Prolonged labor § Prolonged rupture of
membranes § Unhygienic labor practices § Multiple cervical exams
Preventative Strategies § Partograph § Labor hygiene
3
Global Survey on Puerperal Infection Prevention and Management
§ Questions about clinical guidance and actual practice
§ Preventative measures and management
§ Responses from MCHIP implementing programs: 20/28 countries
COUNTRIES Afghanistan Madagascar Bangladesh Malawi Bolivia Mozambique Ethiopia Malawi Ghana Nigeria Guinea Paraguay India Rwanda Indonesia Tanzania Kenya Zambia Liberia Zimbabwe
4
Antibiotics for Birth or Episiotomy: Policy and Practice
0%
100%
Na#onal clinical guidelines recommend prophylac#c an#bio#cs for normal birth?
Yes
No
20%
80%
Do most providers rou#nely use prophylac#c an#bio#cs
for normal birth?
Yes
No
0%
100%
Na#onal clinical guidelines recommend prophylac#c an#bio#cs for episiotomy?
Yes
No
20%
80%
Do most providers rou#nely use an#bio#cs for
episiotomy?
Yes
No
Afghanistan
Bangladesh
Bolivia
Ethioipa
Ghana
Guinea
India
Indonesia
Kenya
Liberia
Madagascar
Malaw
i
Mozam
bique
Nepal
Nigeria
Paraguay
Rwanda
Tanzania
Zambia
Zimbabw
e
YES
NO
Antibiotic Prophylaxis for Procedures
Afghanistan
Bangladesh
Bolivia
Ethioipa
Ghana
Guinea
India
Indonesia
Kenya
Liberia
Madagascar
Malaw
i
Mozam
bique
Nepal
Nigeria
Paraguay
Rwanda
Tanzania
Zambia
Zimbabw
e
Y E S
NO
70%
30%
Prophylac#c an#bio#cs before caesarian sec#on
Yes
No 60%
40%
Prophylac#c an#bio#cs before manual removal of placenta
Yes
No
Guidelines on Cervical Exams and AROM
Afghanistan
Bangladesh
Bolivia
Ethioipa
Ghana
Guinea
India
Indonesia
Kenya
Liberia
Madagascar
Malaw
i
Mozam
bique
Nepal
Nigeria
Paraguay
Rwanda
Tanzania
Zambia
Zimbabw
e
YES
NO
95%
5%
Na#onal clinical guidelines: Frequency of cervical exams during labor?
Yes
No
90%
10%
Na#onal clinical guidelines: When to perform ar#ficial rupture of membranes?
Yes
No
Antibiotics to Treat Chorioamnionitis or Endometritis
8 100%
0%
Na#onal clinical guidelines on use of an#bio#cs to treat
chorioamnioni#s?
Yes
No 90%
10%
Na#onal clinical guidelines on use of an#bio#cs to treat puerperal
endometri#s?
Yes
No 75%
25%
Na#onal clinical guidelines on how long to treat endometri#s
with an#bio#cs?
Yes
No
Afghanistan
Bangladesh
Bolivia
Ethioipa
Ghana
Guinea
India
Indonesia
Kenya
Liberia
Madagascar
Malaw
i
Mozam
bique
Nepal
Nigeria
Paraguay
Rwanda
Tanzania
Zambia
Zimbabw
e
YES
NO
9
Quality of Care Surveys 2010
§ By MCHIP and host countries
§ Direct observation of clinical practices
§ 5 countries: Kenya, Tanzania, Ethiopia, Madagascar and Rwanda
Availability of infection prevention supplies in the delivery room
Notes: Bars represent average of mean scores for all countries and high-low error bars show the by-country range.
N= 597 facilities
73% 96% 90% 88% 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Soap and piped water/bucket with tap
Sharps container Already mixed decontaminating solution
Clean (or sterile) gloves
Quality of infection prevention during labor & delivery
41%
40%
92%
57%
94%
87%
95%
30%
75%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Initial assessment: Washes his/her hands before any examination
1st stage: Washes his/her hands before any examination
Wears high-level disinfected or sterile gloves for vaginal examination
Puts on clean protective clothing in preparation for birth
Disposes of all sharps in puncture-proof container
Decontaminates all reusable instruments in 0.5% chlorine solution
Disposes of all contaminated waste in leakproof containers
Wipes apron with 0.5% chlorine solution
Washes hands after birth
Notes: Bars represent average of mean scores for all countries and high-low error bars show the by-country range.
N= 2164 observations
Quality of partograph use
58% 45% 23% 36% 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Partograph used during labor
Partograph initiated at appropriate time
Plotted at least every half hour during labor
Delivery information recorded
Notes: Bars represent average of mean scores for all countries and high-low error bars show the by-country range.
N= 2164 observations
Conclusions
§ Prevention, early diagnosis and proper treatment of maternal infection crucial
§ Policies and guidelines on IP and use of ABX are generally accurate
§ Practices do not always conform to national guidelines
§ Further understanding of approaches for prevention and management of maternal infection is needed
14!Thank you!
Thank you!
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