Dr jeffrey smith 0

Puerperal Sepsis Global Overview

Jeffrey Smith, MD, MPH Maternal Health Director

Seth Rosenblatt, MPH Sr. Program Officer

Global Forum on Bacterial Infections & Antibiotic Resistance New Delhi, October 2011

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

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Contributing Factors and Prevention Contributing Factors § Prolonged labor § Prolonged rupture of membranes § Unhygienic labor practices § Multiple cervical exams

Preventative Strategies § Partograph § Labor hygiene

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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

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COUNTRIES Afghanistan

Madagascar

Bangladesh

Malawi

Bolivia

Mozambique

Ethiopia

Malawi

Ghana

Nigeria

Guinea

Paraguay

India

Rwanda

Indonesia

Tanzania

Kenya

Zambia

Liberia

Zimbabwe

Antibiotics for Birth or Episiotomy: Policy and Practice YES

NO

Zimbabwe

Zambia

Tanzania

Rwanda

Paraguay

Nigeria

Nepal

Na#onal clinical guidelines recommend prophylac#c an#bio#cs for episiotomy?

Do most providers rou#nely use an#bio#cs for episiotomy?

0%

0%

20%

20%

100%

Mozambique

Malawi

Do most providers rou#nely use prophylac#c an#bio#cs for normal birth?

Madagascar

Liberia

Kenya

Indonesia

India

Guinea

Ghana

Ethioipa

Bolivia

Bangladesh

Afghanistan

Na#onal clinical guidelines recommend prophylac#c an#bio#cs for normal birth?

Yes

Yes

Yes

No

No

No

80%

100%

Yes 80%

No

Antibiotic Prophylaxis for Procedures Y E S

N O

60%

Yes

Yes

No

No 70%

Zimbabwe

30%

40%

Zambia

Tanzania

Rwanda

Paraguay

Nigeria

Nepal

Mozambique

Malawi

Madagascar

Liberia

Kenya

Indonesia

India

Guinea

Ghana

Ethioipa

Bolivia

Bangladesh

Afghanistan

Prophylac#c an#bio#cs before caesarian sec#on

Prophylac#c an#bio#cs before manual removal of placenta

Guidelines on Cervical Exams and AROM

YES

NO

Zimbabwe

Zambia

Tanzania

Rwanda

Paraguay

Nigeria

Nepal

Mozambique

Malawi

Madagascar

Liberia

5%

Kenya

Indonesia

India

Guinea

Ghana

Ethioipa

Bolivia

Bangladesh

Afghanistan

Na#onal clinical guidelines: Frequency of cervical exams during labor?

Na#onal clinical guidelines: When to perform ar#ficial rupture of membranes?

10%

Yes

Yes

No

95%

No 90%

Antibiotics to Treat Chorioamnionitis or Endometritis

YES

N O

Na#onal clinical guidelines on how long to treat endometri#s with an#bio#cs?

10%

Yes

No

8 90%

No

25%

Yes 75%

No

Zimbabwe

Zambia

Tanzania

Rwanda

Paraguay

Nigeria

Nepal

Mozambique

Malawi

Na#onal clinical guidelines on use of an#bio#cs to treat puerperal endometri#s?

Yes 100%

Madagascar

Liberia

Kenya

Indonesia

0%

India

Guinea

Ghana

Ethioipa

Bolivia

Bangladesh

Afghanistan

Na#onal clinical guidelines on use of an#bio#cs to treat chorioamnioni#s?

Quality of Care Surveys 2010 § By MCHIP and host countries § Direct observation of clinical practices § 5 countries: Kenya, Tanzania, Ethiopia, Madagascar and Rwanda

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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.

100% 90% 80% 70% 60% 50% 40% 30% 20% 10%

73%

96%

Soap and piped water/ bucket with tap

Sharps container

90%

88%

0%

Already mixed Clean (or sterile) gloves decontaminating solution

N= 597 facilities

Quality of infection prevention during labor & delivery Notes: Bars represent average of mean scores for all countries and high-low error bars show the by-country range.

Initial assessment: Washes his/her hands before any examination

41%

1st stage: Washes his/her hands before any examination 40% Wears high-level disinfected or sterile gloves for vaginal examination

92%

Puts on clean protective clothing in preparation for birth

57%

Disposes of all sharps in puncture-proof container

94%

Decontaminates all reusable instruments in 0.5% chlorine solution

87%

Disposes of all contaminated waste in leakproof containers

95%

Wipes apron with 0.5% chlorine solution

30%

Washes hands after birth

75% 0%

10%

20%

N= 2164 observations

30%

40%

50%

60%

70%

80%

90%

100%

Quality of partograph use Notes: Bars represent average of mean scores for all countries and high-low error bars show the by-country range.

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 58%

45%

23%

36%

0%

Partograph used during labor

Partograph initiated at Plotted at least every half appropriate time hour during labor N= 2164 observations

Delivery information recorded

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

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