In this case-control study, factors associated with early-onset neonatal sepsis (EONS) among term babies delivered by caesarean section at MRRH, Southwestern Uganda were maternal referral from other health facilities, primigravida status, antepartum hemorrhage, multiple vaginal examinations after rupture of membranes, and a decision-to-delivery time exceeding one hour for emergency caesarean sections.
Term neonates born to mothers referred from other health facilities had higher odds of developing EONS than those born to non-referred mothers. This is in agreement with findings from a study conducted at Mulago National Hospital (Central Uganda), and in Eastern Uganda[21, 22]. This heightened risk may be attributed to several factors commonly observed in referral cases, including poor labor progress and pre-referral interventions such as herbal remedies and artificial membrane rupture, which can predispose newborns to infections. On the basis of this finding, clinical care teams should consider screening neonates born to referred mothers for signs and symptoms of early-onset neonatal sepsis to aid in its prompt detection and management.
Babies born to mothers with a prolonged decision-to-delivery time interval had increased odds of EONS. Similar findings, where longer decision-to-delivery interval has been associated with poor perinatal outcomes, including EONS, were reported in other sub-Saharan African countries, including Rwanda, and Kenya; and in Nepal[23–25]. This interval is crucial for feto-maternal outcomes in category-1 emergency caesarean sections and can lead to delays in emergency obstetric care, prolonging labor and increasing the risk of neonatal sepsis[26]. Neonates born after a long decision-to-delivery interval in an emergency caesarean section have increased odds of Apgar scores of < 7 in the first and fifth minutes [27]. Babies with birth asphyxia face a increased risk of neonatal infection, likely due to the need for resuscitation, which has been associated with EONS in previous studies[28]. Infections can result from poor practices and non-adherence to guidelines by health professionals during resuscitation, predisposing neonates to infectious microorganisms and increasing the risk of neonatal sepsis [29]. Implementing standard operating procedures to deliberately reduce the decision-to-delivery time for emergency cesarean sections to less than an hour could reduce the burden of EONS and potentially improve neonatal outcomes in this setting.
Babies born to mothers with antepartum hemorrhage had increased odds of EONS. Our finding is consistent with a study done in Ghana [19]. This is because there is exposure of the intrauterine environment to ascending infections from the genital tract following a break in the cervical plug, and blood, acting as a culture medium, enhances the growth of offending microorganisms, thereby increasing the risk of early-onset neonatal sepsis. Intrauterine infections can also lead to antepartum hemorrhage, predisposing the fetus to EONS[30].
Babies born to primigravida women had higher odds of developing EONS compared to those born to multigravida women. This finding is consistent with previous studies that have found primiparous women to be at higher risk for neonatal sepsis compared to multiparous women [19, 28, 29, 31, 32]. Our finding may be explained by the complications of labor commonly present in first-time mothers, such as obstructed and prolonged labor. Additionally, the anxiety associated with first-time labor experiences may lead these mothers to frequently request examinations, resulting in multiple vaginal examinations and an increased risk of infection, as observed in Nepal [28].
Babies born to mothers who had multiple (> 3) vaginal examinations after rupture of membranes had higher odds of developing EONS compared to those who had three or less. Similar findings were observed in previous studies [33–35]. This is because EONS is primarily caused by ascending organisms from the maternal genital tract. Multiple vaginal examinations after rupture of membranes can facilitate contamination of the intrauterine environment, leading to chorioamnionitis and, subsequently, neonatal sepsis from ascending infection. The pathogen may ascend through multiple vaginal examinations when the amniotic membranes rupture or before the onset of labor, causing an intra-amniotic infection that can be transmitted to the fetus, as observed in a study in the USA [36]. To mitigate the risk of EONS, clinicians should consider restricting the number of vaginal examinations following rupture of membranes. If multiple examinations are deemed necessary, administering intrapartum prophylactic antibiotics could be considered.
This study has some limitations. First and foremost, it is prone to recall bias. However, we mitigated this by not solely relying on self-reported data but also extracting information from patients' medical records. Secondly, our diagnosis of early-onset neonatal sepsis did not include blood culture, potentially leading to differential misclassification of cases (over-ascertainment) and biasing our associations away from the null. Future studies should include microbiological analyses to better understand the etiological agents of EONS among babies born to mothers delivering by caesarean section in the region. This information will be crucial for informing evidence-based prevention and control strategies.