Maternal and institutional characteristics associated with the administration of prophylactic antibiotics for caesarean section: a secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health

Compliance with Antibiotic Prophylaxis in Obstetric and Gynecological Surgeries in Two Peruvian Hospitals

INTRODUCTION

Surgical site infections (SSI) can be as high in gynecology and obstetrics surgeries compared to other areas. Antimicrobial prophylaxis is an effective tool in the prevention of SSIs; however, it is often not adequately administered, so this study aimed to understand the compliance and factors associated with the use of the clinical practice guidelines for antibiotic prophylaxis in gynecological surgeries in two hospitals in the city of Huanuco, Peru.

METHODS

An analytical cross-sectional study of all gynecologic surgeries performed during 2019 was performed. Compliance was determined based on the antibiotic chosen, dose, administration time, redosing, and prophylaxis duration. Age, hospital of origin, presence of comorbidities, surgery performed, as well as its duration, types of surgery, and anesthesia were considered as related factors.

RESULTS

We collected 529 medical records of patients undergoing gynecological surgery with a median age of 33 years. The prophylactic antibiotic was correctly indicated in 55.5% of cases, and the dose was correct in 31.2%. Total compliance with the five variables evaluated was only 3.9%. Cefazolin was the most commonly used antibiotic.

CONCLUSION

Low compliance with the institutional clinical practice guidelines for antibiotic prophylaxis was identified, showing that antimicrobial prophylaxis in the hospitals studied was inadequate.

Factors affecting the use of antibiotics and antiseptics to prevent maternal infection at birth: A global mixed-methods systematic review

Background

Over 10% of maternal deaths annually are due to sepsis. Prophylactic antibiotics and antiseptic agents are critical interventions to prevent maternal peripartum infections. We conducted a mixed-method systematic review to better understand factors affecting the use of prophylactic antibiotics and antiseptic agents to prevent peripartum infections.

Methods

We searched MEDLINE, EMBASE, Emcare, CINAHL, Global Health, Global Index Medicus, and Maternity and Infant Care for studies published between 1 January 1990 and 27 May 2022. We included primary qualitative, quantitative, and mixed-methods studies that focused on women, families, and healthcare providers’ perceptions and experiences of prophylactic antibiotic and antiseptics during labour and birth in health facilities. There were no language restrictions. We used a thematic synthesis approach for qualitative evidence and GRADE-CERQual approach for assessing confidence in these review findings. Quantitative study results were mapped to the qualitative findings and reported narratively.

Results

We included 19 studies (5 qualitative, 12 quantitative and 2 mixed-methods studies), 16 relating to antibiotics, 2 to antiseptic use, and 1 study to both antibiotic and antiseptic use. Most related to providers’ perspectives and were conducted in high-income countries. Key themes on factors affecting antibiotic use were providers’ beliefs about benefits and harms, perceptions of women’s risk of infection, regimen preferences and clinical decision-making processes. Studies on antiseptic use explored women’s perceptions of vaginal cleansing, and provider’s beliefs about benefits and the usefulness of guidelines.

Conclusion

We identified a range of factors affecting how providers use prophylactic antibiotics at birth, which can undermine implementation of clinical guidelines. There were insufficient data for low-resource settings, women’s perspectives, and regarding use of antiseptics, highlighting the need for further research in these areas. Implications for practice include that interventions to improve prophylactic antibiotic use should take account of local environments and perceived infection risk and ensure contextually relevant guidance.

Antibiotic Usage in Patients Having Undergone Caesarean Section: A Three-Level Study in Benin

The intense use and misuse of antibiotics is undoubtedly the main factor associated with the high numbers of antibiotic-resistant pathogenic and commensal bacteria worldwide. In low-income countries, this misuse and overuse is widespread, with great consequences at the personal and global levels. In the context of user fee exemptions in caesarean sections, we performed a descriptive study in women to assess the use of antibiotics on three levels-antenatal, during caesarean section, and postpartum-in four Beninese hospitals. Out of the 141 women included, 56.7% were using antibiotics. More than the half (71.3%) were taking more than one antibiotic, either for a long time or in acute treatment. In prophylaxis, the timing, dose, and duration of administration were not correctly achieved. Only 31.2% of women received optimal antibiotic prophylaxis. Various antibiotics including broad-spectrum molecules were used in the patients after caesarean section. The use of antibiotics was improper on the three levels studied. The high rate of self-administered antibiotics, the poor achievement of antibiotic prophylaxis, and the postpartum overuse of antibiotics showed a poor quality of care provided in pregnancy. A national policy is essential to improve the use of antibiotics by the general public as well as by professionals.

Overuse of antibiotics in maternity and neonatal wards, a descriptive report from public hospitals in Dar es Salaam, Tanzania

BACKGROUND

Overuse of antibiotics is a major challenge and undermines measures to control drug resistance worldwide. Postnatal women and newborns are at risk of infections and are often prescribed prophylactic antibiotics although there is no evidence to support their universal use in either group.

METHODS

We performed point prevalence surveys in three hospitals in Dar es Salaam, Tanzania, in 2018 to collect descriptive data on antibiotic use and infections, in maternity and neonatal wards.

RESULTS

Prescribing of antibiotics was high in all three hospitals ranging from 90% (43/48) to 100% (34/34) in women after cesarean section, from 1.4% (1/73) to 63% (30/48) in women after vaginal delivery, and from 89% (76/85) to 100% (77/77) in neonates. The most common reason for prescribing antibiotics was medical prophylaxis in both maternity and neonatal wards.

CONCLUSIONS

We observed substantial overuse of antibiotics in postnatal women and newborns. This calls for urgent antibiotic stewardship programs in Tanzanian hospitals to curb this inappropriate use and limit the spread of antimicrobial resistance.

Surgical Site Infections and Antimicrobial Resistance After Cesarean Section Delivery in Rural Rwanda

Background:

As the volume of surgical cases in low- and middle-income countries (LMICs) increases, surgical-site infections (SSIs) are becoming more prevalent with anecdotal evidence of antimicrobial resistance (AMR), despite a paucity of data on resistance patterns.

Objectives:

As a primary objective, this prospective study aimed to describe the epidemiology of SSIs and the associated AMR among women who delivered by cesarean at a rural Rwandan hospital. As secondary objectives, this study also assessed patient demographics, pre- and post-operative antibiotic use, and SSI treatment.

Methods:

Women who underwent cesarean deliveries at Kirehe District Hospital between September 23rd, 2019, and March 16th, 2020, were enrolled prospectively. On postoperative day (POD) 11 (+/– 3 days), their wounds were examined. When an SSI was diagnosed, a wound swab was collected and sent to the Rwandan National Reference Laboratory for culturing and antibiotic susceptibility testing.

Findings:

Nine hundred thirty women were enrolled, of whom 795 (85.5%) returned for the POD 11 clinic visit. 45 (5.7%) of the 795 were diagnosed with SSI and swabs were collected from 44 of these 45 women. From these 44 swabs, 57 potential pathogens were isolated. The most prevalent bacteria were coagulase-negative staphylococci (n = 12/57, 20.3% of all isolates), and Acinetobacter baumannii complex (n = 9/57, 15.2%). 68.4% (n = 39) of isolates were gram negative; 86.7% if excluding coagulase-negative staphylococci. No gram-negative pathogens isolated were susceptible to ampicillin, and the vast majority demonstrated intermediate susceptibility or resistance to ceftriaxone (92.1%) and cefepime (84.6%).

Conclusions:

Bacterial isolates from SSI swab cultures in rural Rwanda predominantly consisted of gram-negative pathogens and were largely resistant to commonly used antibiotics. This raises concerns about the effectiveness of antibiotics currently used for surgical prophylaxis and treatment and may guide the appropriate selection of treatment of SSIs in rural Rwanda and comparable settings.

Risk factors for Caesarean sections in Ghana: evidence from the Ghana Maternal Health Survey

A Caesarean section can be a life-saving intervention in case of pregnancy complications or difficult labour. The prevalence of Caesarean section continues to increase, especially in sub-Saharan Africa, yet the reasons for this remain largely unexplored. This study investigated risk factors contributing to the decision to perform Caesarean sections in Ghana using data from 8645 women aged 15-49 years from the 2017 Ghana Maternal Health Survey. The data were analysed by applying complementary log-log and logit models. The majority of Ghanaian women (about 87%) reported preferring vaginal delivery to Caesarean section. Of those who had undergone a Caesarean section for their most recent birth, about 55% had an elective rather than an emergency section. Women with labour complications (prolonged/obstructed labour) were significantly more likely to have a Caesarean section (OR=4.09, 95% CI=3.10-5.41). Furthermore, women with maternal complications, particularly prolonged/obstructed labour, were less likely to have an elective Caesarean section than those who had no such complications (OR=0.25, 95% CI=0.14-0.46). Compared with poorer women, wealthy women were significantly more likely to have an elective Caesarean section (OR=1.84, 95% CI=1.08-3.14). The findings suggest that beyond maternal complications, women's socioeconomic and demographic characteristics are important risk factors for undergoing a Caesarean section in Ghana.

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

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.

Provision of intensive care to severely ill pregnant women is associated with reduced mortality: Results from the WHO Multicountry Survey on Maternal and Newborn Health

OBJECTIVE

To estimate the impact of the use of Intensive Care Units (ICU) in maternal mortality.

METHODS

A secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health, a multicenter cross-sectional study conducted in maternity hospitals in 29 countries. Women who had severe maternal outcome (maternal death or maternal near-miss) and the availability and use of ICU beds were included. The women were categorized according to availability of ICU, and multivariate logistic regression analyses were performed to determine the risk of maternal death. To rate the severity of complications, the Maternal Severity Score (MSS) and the Maternal Severity Index (MSI) were used.

RESULTS

Of 314 623 women observed, 24 396 had severe complications. Of those, 16 981 (69.6%) were in facilities with ICUs; 1573 women were admitted to ICUs (6.4% of women with maternal complications and 0.5% of total). There is a significant protective effect for maternal mortality for patients with more severe conditions using ICUs (odds ratio 0.16, 95% confidence interval 0.07-0.33).

CONCLUSION

The use of ICU was associated with significantly reduced odds of maternal death in obstetric patients with severe clinical conditions. The availability and appropriate use of good-quality ICUs are therefore crucial to reduce maternal mortality.

Caesarean delivery associated with adverse breastfeeding practices: a prospective cohort study

Caesarean delivery rates are increasing in many Asian countries. This study investigated the effects of caesarean section on breastfeeding practices from delivery to twelve months postpartum. A prospective cohort study was conducted on 2030 pregnant women recruited from three cities in Vietnam during 2015-2017. The overall caesarean rate was 38.1%. Mothers who underwent caesarean section were more likely to give prelacteal feeds to their infants (adjusted odds ratio (OR) 13.91, 95% confidence interval (CI) 10.52-18.39) and as a result have lower rates of early initiation of breastfeeding (adjusted OR 0.04, 95%CI 0.02-0.05). Having a caesarean section reduced the likelihood of (any, predominant and exclusive) breastfeeding from discharge to 6 months postpartum. After 1 year, the any breastfeeding rate was still lower in the caesarean delivery (70.2%) compared with the vaginal delivery group (72.9%), p = .232. Vietnamese women who give birth by caesarean section need extra support to initiate and maintain breastfeeding.IMPACT STATEMENTWhat is already known on this subject? Early initiation of breastfeeding, and 'exclusive' or 'predominant' breastfeeding rates at discharge are lower in mothers delivering by caesarean section compared to vaginal delivery. Prelacteal feeding rates are higher following caesarean section. However, the association between 'any' breastfeeding duration and caesarean delivery has not been established.What the results of this study add? This study showed that caesarean delivery reduced all breastfeeding rates from discharge to six months and any breastfeeding rate at 12 months postpartum in Vietnamese women.What the implications are of these findings for clinical practice and/or further research? Further breastfeeding interventions are needed during the postpartum period for mothers who deliver by caesarean section.

Secondary analysis of the WOMAN trial to explore the risk of sepsis after invasive treatments for postpartum hemorrhage

OBJECTIVE

To examine the association between the use of invasive treatments for postpartum hemorrhage and the risk of sepsis and severe sepsis.

METHODS

Secondary data analysis of the WOMAN randomized controlled trial, including 20 060 women with postpartum hemorrhage in 21 countries. Logistic regression with random effects was used.

RESULTS

The cumulative incidence was 1.8% for sepsis and 0.5% for severe sepsis. All-cause mortality was 40.4% in women with severe sepsis versus 2.2% for women without. After adjusting for bleeding severity and other confounders, intrauterine tamponade, hysterectomy, and laparotomy increased the risk of sepsis (aOR 1.77 [95% CI 1.21-2.59], P=0.004; aOR 1.97 [95% CI 1.49-2.65], P<0.001; and aOR 6.63 [95% CI 4.29-10.24], P<0.001, respectively) and severe sepsis (aOR 2.60 [95% CI 1.47-4.59], P=0.002; aOR 1.97 [95% CI 0.83-2.46], P=0.033; and aOR 5.35 [95% CI 2.61-10.98], P<0.001, respectively).

CONCLUSION

In this secondary data analysis, certain invasive treatments for postpartum hemorrhage appear to increase the risk of sepsis. Further research is needed to confirm this finding and investigate the role of prophylactic antibiotics during these procedures. The harms and benefits of such interventions must be carefully weighed, both in treatment guidelines and during individual patient management.

TRIAL REGISTRATION

ISRCTN76912190.

Cluster analysis identifying clinical phenotypes of preterm birth and related maternal and neonatal outcomes from the Brazilian Multicentre Study on Preterm Birth

OBJECTIVE

To explore a conceptual framework of clinical conditions associated with preterm birth (PTB) by cluster analysis, assessing determinants for different PTB subtypes and related maternal and neonatal outcomes.

METHODS

Secondary analysis of the Brazilian Multicentre Study on Preterm Birth of 33 740 births in 20 maternity hospitals between April 2011 and July 2012. In accordance with a prototype concept based on maternal, fetal, and placental conditions, an adapted k-means model and fuzzy algorithm were used to identify clusters using predefined conditions. The mains outcomes were phenotype clusters and maternal and neonatal outcomes.

RESULTS

Among 4150 PTBs, three clusters of PTB phenotypes were identified: women who had PTB without any predefined conditions; women with mixed conditions; and women who had pre-eclampsia, eclampsia, HELLP syndrome and fetal growth restriction. The prevalence of different preterm subtypes differed significantly in the three clusters, varying from 80.95% of provider-initiated PTBs in cluster 3-6.62% in cluster 1 (P<0.001). Although some maternal characteristics differed among the clusters, maternal and neonatal outcomes did not.

CONCLUSIONS

The analysis identified three clusters with distinct phenotypes. Women from the different clusters had different subtypes of PTB and maternal and pregnancy characteristics.

Antibiotic Treatment and Length of Hospital Stay in Relation to Delivery Mode and Prematurity

Aim

To investigate how 1) maternal delivery mode and 2) prematurity in infants are associated to antibiotic treatment and length of hospital stay.

Methods

Women having given birth and infants 0–12 months discharged from hospital between July 2005 and November 2011 were identified from the Swedish National Patient Register. Medical records were reviewed for 203 women and 527 infants. The risk ratio (RR) between antibiotic treatment and 1) delivery mode in women; 2) prematurity in infants was calculated. Length of stay and days of antibiotic therapy were compared by Wilcoxon rank-sum test.

Results

Women: There was an association between emergency caesarean section (CS) and antibiotic treatment (RR 5.0 95% confidence interval (CI) 2.2–11.5), but not for elective CS. Length of stay was longer for CS (emergency and elective) compared to vaginal delivery (p<0.01). Infants: RR for antibiotic treatment in preterm compared to term infants was 1.4 (95% CI 1.0–1.9). Length of stay (p<0.01), but not days of therapy (p = 0.17), was higher in preterm compared to term infants.

Conclusion

We found that emergency CS increased the probability of maternal antibiotic treatment during hospitalisation, but no difference was found between term and preterm infants. The results are well aligned with current guidelines and may be considered in future studies on the effects of antibiotics.

Maternal, fetal and neonatal mortality: lessons learned from historical changes in high income countries and their potential application to low-income countries

BACKGROUND

There are large differences in pregnancy outcome between high income countries and many middle and low income countries. In fact, maternal, fetal and neonatal mortality rates in many low-income countries approximate those that were seen in high-income countries nearly a century ago.

FINDINGS

This paper documents the very substantial reductions in maternal, fetal and neonatal mortality rates in high income countries over the last century and explores the likely reasons for those reductions. The conditions responsible for the current high mortality rates in low and middle income countries are discussed as are the interventions likely to result in substantial reductions in maternal, fetal and neonatal mortality from those conditions. The conditions that result in maternal mortality are often responsible for fetal and neonatal mortality and the interventions that save maternal lives often reduce fetal and neonatal mortality as well. Single interventions rarely achieve substantial reductions in mortality. Instead, upgrading the system of care so that appropriate interventions could be applied at appropriate times is most likely to achieve the desired reductions in maternal, fetal and neonatal mortality.

Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section

BACKGROUND

The single most important risk factor for postpartum maternal infection is cesarean section. Although guidelines endorse the use of prophylactic antibiotics for women undergoing cesarean section, there is not uniform implementation of this recommendation. This is an update of a Cochrane review first published in 1995 and last updated in 2010.

OBJECTIVES

To assess the effects of prophylactic antibiotics compared with no prophylactic antibiotics on infectious complications in women undergoing cesarean section.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2014) and reference lists of retrieved papers.

SELECTION CRITERIA

Randomized controlled trials (RCTs) and quasi-RCTs comparing the effects of prophylactic antibiotics versus no treatment in women undergoing cesarean section.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. The clinically important primary outcomes were wound infection, endometritis, serious maternal infectious complications and adverse effects on the infant. We presented dichotomous data as risk ratios (RR), with 95% confidence intervals (CIs) and combined trials in meta-analyses. We assessed the quality of evidence using the GRADE approach.

MAIN RESULTS

We identified 95 studies enrolling over 15,000 women. Compared with placebo or no treatment, the use of prophylactic antibiotics in women undergoing cesarean section reduced the incidence of wound infection (RR 0.40, 95% CI 0.35 to 0.46, 82 studies, 14,407 women), endometritis (RR 0.38, 95% CI 0.34 to 0.42, 83 studies, 13,548 women) and maternal serious infectious complications (RR 0.31, 95% CI 0.20 to 0.49, 32 studies, 6159 women). When only studies that included women undergoing an elective cesarean section were analyzed, there was also a reduction in the incidence of wound infections (RR 0.62, 95% CI 0.47 to 0.82, 17 studies, 3537 women) and endometritis (RR 0.38, 95% CI 0.24 to 0.61, 15 studies, 2502 women) with prophylactic antibiotics. Similar estimates of effect were seen whether the antibiotics were administered before the cord was clamped or after. The effect of different antibiotic regimens was studied and similar reductions in the incidence of infections were seen for most of the antibiotics and combinations.There were no data on which to estimate the effect of maternal administration of antibiotics on infant outcomes. No studies systematically collected and reported on adverse infant outcomes nor the effect of antibiotics on the developing infant immune system. No studies reported on the incidence of oral candidiasis (thrush) in babies. Maternal adverse effects were also rarely described.We judged the evidence for antibiotic treatment compared with no treatment to be of moderate quality; most studies lacked an adequate description of methods and were assessed as being at unclear risk of bias.

AUTHORS' CONCLUSIONS

The conclusions of this review support the recommendation that prophylactic antibiotics should be routinely administered to all women undergoing cesarean section to prevent infection. Compared with placebo or no treatment, the use of prophylactic antibiotics in women undergoing cesarean section reduced the incidence of wound infection, endometritis and serious infectious complications by 60% to 70%. There were few data on adverse effects and no information on the effect of antibiotics on the baby, making the assessment of overall benefits and harms difficult. Prophylactic antibiotics given to all women undergoing elective or non-elective cesarean section is beneficial for women but there is uncertainty about the consequences for the baby.