Determinants of puerperal sepsis among mothers who give birth at Jigjiga public hospitals, Somali Regional State, Eastern Ethiopia

doi:10.21203/rs.3.rs-4970368/v1

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Determinants of puerperal sepsis among mothers who give birth at Jigjiga public hospitals, Somali Regional State, Eastern Ethiopia

https://doi.org/10.21203/rs.3.rs-4970368/v1

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Introduction: Puerperal sepsis is a significant public health concern in low-resource settings, including Ethiopia, where it is a major contributor to maternal mortality, accounting for 13% of maternal deaths. We investigated the determinants of puerperal sepsis among mothers who give birth at Jigjiga Public Hospitals, Somali Regional State, Eastern Ethiopia.

Methods:A facility-based unmatched case-control design was employed, with a sample size of 227 (76 cases and 151 controls). The study was conducted at two public hospitals in Jigjiga, Eastern Ethiopia, from January 2022 to December 2022. Data was collected using a standardized structured questionnaire and medical record review. Data were analyzed using SPSS software version 26. Multivariate logistic regression analysis was used to identify the determinants of puerperal sepsis. The level of significance was set at 0.05.

Results: The mean age of the mothers was 30.2±10.2 years for cases and 31.5±6.7 years for controls. The results showed that not attending antenatal care regularly (aOR: 3.2, 95% CI: 1.483-6.940), having fewer antenatal care follow-ups (aOR: 3.3, 95% CI: 1.608-6.589), membranes rupturing for less than 24 hours (aOR: 4.6, 95% CI: 1.933-11.028), and having fewer pelvic examinations (aOR: 12.1, 95% CI: 2.873-19.131) were determinants of puerperal sepsis.

Conclusion: The study found that several factors were associated with puerperal sepsis, including irregular antenatal care attendance, fewer antenatal follow-ups, delayed membrane rupture, and fewer pelvic examinations. To address this issue, healthcare providers and policymakers should prioritize improving access to quality antenatal care, empowering mothers through education and enhancing maternal education, and implementing evidence-based guidelines for managing obstetric complications.

Case-control

Determinants

Eastern Ethiopia

Mothers

Puerperal sepsis

Somali Regional State

Puerperal sepsis remains a serious and life-threatening infection that impacts women during the postpartum period, especially in low-resource settings such as Ethiopia [1]. It is a major contributor to maternal morbidity and mortality worldwide, accounting for around 11% of maternal deaths, with the highest incidence in developing countries where access to quality maternal healthcare is limited [2]. It is estimated that there are between 15 to 19 million cases of maternal sepsis annually, resulting in approximately 75,000 maternal deaths, making it a significant public health

concern [3–5].

In Africa, the prevalence of puerperal sepsis is higher than the global average, ranging from 8–15% [6, 7]. In Ethiopia, where maternal mortality rates remain high despite recent improvements in healthcare access and quality, puerperal sepsis is the fourth leading cause of maternal mortality, contributing for 13% of all maternal death [8, 9]. According to the 2016 Ethiopia Demographic and Health Survey (EDHS) report, the maternal mortality ratio was 412 per 100,000 live births. Therefore, four women died during pregnancy, childbirth, or within two months of giving birth for every 1,000 live births [10].

Puerperal sepsis is a significant public health concern in Jigjiga Public hospitals, Somali Regional State, Eastern Ethiopia, where it is associated with high maternal morbidity and mortality rates. Despite this, there is limited understanding of the determinants of puerperal sepsis in this setting. Identifying the determinants of puerperal sepsis is crucial for the development of targeted interventions to reduce its incidence and improve maternal outcomes. This study investigated the determinants of puerperal sepsis among mothers who give birth at Jigjiga Public Hospitals in Jigjiga, Somali Regional State, eastern Ethiopia.

Study Design, Period and Setting

This study employed a facility-based unmatched case-control design to investigate the determinants of puerperal sepsis among mothers who delivered at Jigjiga public hospitals between January 2022 and December 2022. The Somali Regional State is a regional state located in eastern Ethiopia, which holds the second-largest territory in the country after the Oromia Region. It is bordered by the Ethiopian regions of Afar and Oromia to the west, Djibouti to the north, Somalia to the northeast, east, and south, and Kenya to the southwest. Jigjiga is the capital city, located 621 kilometers from Addis Ababa, Ethiopia's capital city. The city has a population of approximately 304,400 people, comprising 151,422 males and 153,578 females [11]. The study was conducted at two public hospitals in Jigjiga, specifically Sultan Sheikh Hassan Yabare Comprehensive Specialized Hospital and Karamara General Hospital. These hospitals provide health services to the local community as well as serving an estimated population of more than 7 million people living in the region, including neighboring districts of the Oromia region, region in northern Somalia (approximately 3.5-5 million according to the standard). The hospitals are responsible for training, teaching, and research for Jigjiga University's College of Medicine and Health Sciences, as well as internship training for students from other health science colleges in the region.

Study Population

The study population comprised all postpartum mothers who delivered at Jigjiga Public hospitals over a 12-month period. The case group consisted of mothers who were admitted with puerperal sepsis, while the control group comprised mothers who did not develop puerperal sepsis and remained hospitalized for more than 24 hours.

Eligibility Criteria

Cases

Postpartum mothers who developed puerperal sepsis within 24 hours after delivery or within 42 days after delivery admitted to Jigjiga Public hospitals during the data collection period were included in the study. Postpartum mothers who had a history of previous puerperal sepsis, who had pre-existing medical conditions, and who had incomplete or inaccurate medical records admitted to Jigjiga Public hospitals during the data collection period were excluded from the study.

Controls

Postpartum mothers who did not develop puerperal sepsis within 24 hours after delivery or within 42 days after delivery, gave birth normally, had a normal pregnancy outcome admitted to Jigjiga Public hospitals during the data collection period were included in the study.

Sample Size Determination

The sample size was determined using the double population proportion formula, with Epi Info 7, taking into account the prevalence of puerperal sepsis based on a previous study in West Ethiopia [12], the desired level of precision (5%), a power of 80%, and an expected odds ratio of 3.4. Therefore, the calculated sample size was calculated to be 216 (72 cases and 144 controls), and considering a 5% non-response rate, the final sample size for this study was 227 (76 cases and 151 controls).

Sampling Procedure

Consecutive sampling was used to select cases from postpartum mothers with puerperal sepsis admitted to the maternity wards of the two public hospitals Sultan Sheikh Hassan Yabare Comprehensive Specialized Hospital and Karamara General Hospital. The total sample size was allocated proportionally to each hospital based on the number of registered puerperal sepsis cases in each hospital. Cases were selected from the medical records of mothers who had developed puerperal sepsis during their postpartum stay. Controls were selected from the same population, but were mothers who did not develop puerperal sepsis during their postpartum stay. Every third case of puerperal sepsis and every third mother without puerperal sepsis were selected from the hospital records until the desired sample size was reached.

Data Collection Tool and Procedure

A standardized questionnaire was utilized to collect data for this study, which was adapted from a previous study conducted in Ethiopia [4, 8, 13]. The questionnaire was initially developed in English and subsequently translated into Somali language, followed by a back-translation into English by independent language experts to ensure consistency between the two versions. The questionnaire comprehensively covers all relevant information necessary to meet the objectives of the study, categorized into the following sections: socio-demographic characteristics, obstetric factors, and maternal and co-morbidities. All collected data were recorded on a specially designed data collection sheet for the study. A team of trained data collectors and supervisors was recruited for this study. Two midwives and two nurses served as data collectors, while a health officer acted as a supervisor. Prior to data collection, a comprehensive one-day training session was conducted by the principal investigator, emphasizing the study's objectives, data recording methods, data quality control measures, and confidentiality protocols. The training also covered the contents of the questionnaire and the approach to be taken when interacting with study participants (cases and controls), with the aim of minimizing information bias and ensuring high-quality data collection.

Data Quality Control

To assure the quality of data, adequate training was given to data collectors and supervisor for one-day duration, the objective of the training is to clearly explain data collectors and supervisor the objective of the study to strengthen their skills about how to interview and approach with the study participants during the actual data collection. The questioners were pre-tested on 5% (4 Cases and 8 Controls) of the total sample size at Jigjiga public hospitals. The Questionnaires were checked for their completeness, validity and consistency by the principal investigator.

Data Analysis

The collected and cleaned data were subsequently entered into Epi data version 3.1 and exported to SPSS version 26 for analysis. Descriptive statistics were performed to examine the distribution of variables, and the results were presented in text, frequency tables, and proportion formats. The Pearson Chi-square test was employed to identify the determinants of puerperal sepsis among mothers who gave birth in Jigjiga public hospitals. Binary logistic regression analysis was conducted to investigate the relationship between puerperal sepsis and the explanatory variables. Variables with a p-value less than 0.25 in the bivariate analysis were selected as candidate variables for multivariate logistic regression modeling to account for confounding variables. The model fitness was subsequently assessed using the Hosmer-Lemeshow test. The strength of the associations between independent and dependent variables was evaluated using odds ratios with 95% confidence intervals. Finally, a statistically significant level was declared at a p-value less than 0.05.

Sociodemographic Characteristics of the Study Participants

A total of 227 participants were included in the study, with 76 cases and 151 controls. The mean age of the mothers was 30.2 ± 10.2 years for cases and 31.5 ± 6.7 years for controls. A majority of mothers, 37 (16.3%) of cases and 86 (37.9%) of controls were between the ages of 25–34 years. A significant proportion, 62 (27.3%) of cases and about half, 123 (54.2%), of controls, were married. Most of the participants, 32 (14.1%) of cases and 55 (24.2%) of controls, had no formal education. The majority of the participants, 43 (19.0%) cases and 87 (38.3%) controls, resided in urban areas. (Table 1)

Table 1

Socio-demographic characteristics of mothers who gave birth in Jigjiga public hospitals, Eastern Ethiopia, 2023 (n = 227)
Variables	Puerperal sepsis status		Total N (%)
Variables	Cases N (%)	Controls N (%)	Total N (%)
Age of the mother (In years)
15–24	18 (7.9%)	19 (8.4%)	37 (16.3%)
25–34	37 (16.3%)	86 (37.9%)	123 (54.2%)
35–44	19 (8.4%)	43 (18.9%)	62 (27.3%)
> 44	2 (0.9%)	3 (1.35%)	5 (2.2%)
Marital Status
Married	62 (27.3%)	123 (54.2%)	185 (81.5%)
Divorced	10 (4.4%)	18 (7.9%)	28 (12.3%)
Widowed	4 (2.5%)	10 (4.4%)	14 (6.2%)
Educational Level
No Formal	32 (14.1%)	55 (24.2%)	87 (38.3%)
Primary	15 (6.6%)	36 (15.9%)	51 (22.5%)
Secondary	16 (7.0%)	32 (14.1%)	48 (21.1%)
University/tertiary	13 (5.8%)	28 (12.3%)	41 (18.2%)
Residence
Urban	43 (19.0%)	87 (38.3%)	130 (57.3%)
Rural	33 (14.5%)	64 (28.2%)	97 (42.7%)

Obstetric Characteristics of the Study Participants

Around a quarter of the cases 54 (23.8%) and nearly half of the controls 108 (47.6%) were grand multiparous. Approximately one-quarter of cases 59 (26.0%) and more than half of controls 117 (51.5%) had received antenatal care (ANC) services. Of those who received ANC follow-up, in most cases 22 (9.7%) and controls 72 (31.7%) visited ANC three or more times. Regarding the duration of labor, 41 (18.0%) of cases and 76 (33.5%) of controls had experienced labor lasting 24 hours or more. The majority of mothers, 59 (26.0%) of cases and 83 (36.6%) of controls, had a duration of rupture of membrane of less than 24 hours. Most cases (71, 31.3%) and controls (116, 51.1%) had pelvic examinations performed fewer than five times. The majority of mothers, 49 (21.6%) of cases and 115 (50.6%) of controls, had spontaneous vaginal deliveries. 49 (21.6%) of cases and 54 (23.8%) of controls underwent episiotomy. A significant proportion of mothers, 62 (27.3%) of cases and 134 (59.0%) of controls, delivered in hospitals. Regarding previous obstetric history, 18 (7.9%) of cases and 28 (12.4%) of controls had a history of bad obstetric outcomes. Additionally, 14 (6.2%) of cases and 24 (10.5%) of controls were referred from other healthcare facilities before giving birth. Among the study population, the majority of cases 56 (24.7%) and controls 123 (54.2%) did not have hypertension. Similarly, most cases 51 (22.5%) and controls 130 (57.2%) did not have diabetic mellitus. Additionally, nearly one-third of the cases 29 (12.8%) and half of the controls 114 (50.2%) had a history of sexually transmitted infections. Furthermore, 58 (25.5%) of the cases and 63 (27.8%) of the controls had anemia. (Table 2).

Table 2

Obstetric characteristics among mothers who gave birth in Jigjiga public hospitals, Eastern Ethiopia, 2023 (n = 227)
Variables	Puerperal sepsis status		Total N (%)
Variables	Cases N (%)	Controls N (%)	Total N (%)
Parity
Primiparous	9 (4.0)	14 (6.1)	23 (10.1)
Multiparous	13 (5.7)	29 (12.8)	42 (18.5)
Grand Multiparous	54 (23.8)	108 (47.6)	162 (71.4)
ANC follow up
Yes	59 (26.0)	117 (51.5)	176 (77.5)
No	17 (7.5)	34 (15.0)	51 (22.5)
Number of ANC follow up (n = 176)
≤ 2 times	37 (16.3)	45 (19.8)	82 (36.1)
≥ 3 times	22 (9.7)	72 (31.7)	94 (41.4)
Duration of labor
< 24 hours	35 (15.4)	75 (33.1)	110 (48.5)
≥ 24 hours	41 (18.0)	76 (33.5)	117 (51.5)
Duration of rupture of membrane
< 24 hours	59 (26.0)	83 (36.6)	142 (62.6)
≥ 24 hours	17 (7.5)	68 (29.9)	85 (37.4%)
Number of pelvic examinations
< 5 times	71 (31.3)	116 (51.1)	187 (82.4)
≥ 5 times	5 (2.2)	35 (15.4)	40 (17.6)
Mode of delivery
Spontaneous vaginal delivery	49 (21.6)	115 (50.6)	164 (72.2)
Instrumental delivery	20 (8.8)	17 (7.5)	37 (16.3)
Cesarean section	7 (3.1)	19 (8.4)	26 (11.5)
Episiotomy
Yes	39 (17.2)	54 (23.8)	93 (41.0)
No	37 (16.3)	97 (42.7)	134 (59.0)
Place of delivery
Home	14 (6.2)	17 (7.5)	31 (13.7)
Hospital	62 (27.3)	134 (59.0)	196 (86.3)
Any previous bad obstetric history
Yes	18 (7.9)	28 (12.4)	46 (20.3)
No	58 (25.5)	123 (54.2)	181 (79.7)
Referral status
Yes	14 (6.2)	24 (10.5)	38 (16.7)
No	62 (27.3)	127 (56.0)	189 (83.3)
Hypertension
Yes	20 (8.8)	28 (12.3)	48 (21.1)
No	56 (24.7)	123 (54.2)	179 (78.9)
Diabetic mellitus
Yes	25 (11.0)	21 (9.3)	46 (20.3)
No	51 (22.5)	130 (57.2)	181 (79.7)
Sexual transmitted infection
Yes	29 (12.8)	37 (16.3)	66 (29.1)
No	47 (20.7)	114 (50.2)	161 (70.9)
Anemia
Yes	58 (25.5)	63 (27.8)	121 (53.3)
No	18 (7.9)	88 (38.8)	106 (46.7)

Determinants of puerperal sepsis

The study found that mothers who were married were twice as likely to develop puerperal sepsis as those who were divorced (aOR: 2.0, 95%CI: 0.318–7.553). Similarly, mothers with primary education were twice as likely to develop puerperal sepsis as those with no formal education (aOR: 1.6, 95% CI: 0.232–10.588). The results also revealed that multiparous women were three times more likely to develop puerperal sepsis compared to primiparous women (those who have had only one pregnancy) (aOR: 2.8, 95% CI: 0.714–5.210). Furthermore, women who did not attend antenatal care (ANC) were three times more likely to develop puerperal sepsis compared to those who attended ANC (aOR: 3.2, 95% CI: 1.483–6.940). Additionally, women who had fewer than three ANC follow-ups were three times more likely to develop puerperal sepsis compared to those who had three or more ANC follow-ups (aOR: 3.3, 95% CI: 1.608–6.589). On the other hand, women whose membranes ruptured for less than 24 hours were five times more likely to develop puerperal sepsis compared to those whose membranes ruptured for 24 hours or more (aOR: 4.6, 95% CI: 1.933–11.028). Mothers who had fewer than five times pelvic examinations were twelve times more likely to develop puerperal sepsis (aOR: 12.1, 95% CI: 2.873–19.131). The study also found that mothers who underwent episiotomy were two times more likely to develop puerperal sepsis compared to those who did not undergo the procedure (aOR: 2.1, 95% CI: 1.009–4.488). Similarly, mothers who did not have a previous bad obstetric history were two times more likely to develop puerperal sepsis compared to those who had a previous bad obstetric history (aOR: 1.8, 95% CI: 0.614–5.557). Mothers who were not referred have a three times higher risk of developing puerperal sepsis compared to those who were referred (aOR: 2.5, 95% CI: 0.936–6.503). Mothers with hypertension had a two times higher risk of developing the condition compared to those without hypertension (aOR: 1.5, 95% CI: 0.587–3.882). (Table 3)

Table 3

Determinants of puerperal sepsis among mothers who gave birth in Jigjiga public hospitals, Eastern Ethiopia, 2023 (n = 227)
Variables	Puerperal sepsis status		Total N (%)	Odd Ratio (95% CI)
Variables	Cases N (%)	Controls N (%)	Total N (%)	COR (95% CI)	AOR (95% CI)
Age of the mother (In years)
15–24	18 (7.9)	19 (8.4)	37 (16.3)	0.7 (0.105–2.713)	0.08 (0.006–1.111)
25–34	37 (16.3)	86 (37.9)	123 (54.2)	1.6 (0.249–3.662)	0.6 (0.050–6.403)
35–44	19 (8.4)	43 (18.9)	62 (27.3)	1.5 (0.233–2.778)	0.3 (0.029–4.117)
> 44	2 (0.9)	3 (1.35)	5 (2.2)	1	1
Marital Status
Married	62 (27.3)	123 (54.2)	185 (81.5)	0.8 (0.239–2.632)	1.6 (0.318–7.553)
Divorced	10 (4.4)	18 (7.9)	28 (12.3)	0.7 (0.179–2.901)	0.9 (0.151–6.038)
Widowed	4 (2.5)	10 (4.4)	14 (6.2)	1	1
Educational Level
No Formal	32 (14.1)	55 (24.2)	87 (38.3)	0.8 (0.363–1.757)	0.7 (0.099–5.536)
Primary	15 (6.6)	36 (15.9)	51 (22.5)	1.1 (0.457–2.719)	1.6 (0.232–10.588)
Secondary	16 (7.0)	32 (14.1)	48 (21.1)	0.9 (0.381–2.262)	1.5 (0.213–2.835)
University/tertiary	13 (5.8)	28 (12.3)	41 (18.2)	1	1
Residence
Urban	43 (19.0)	87 (38.3)	130 (57.3)	1	1
Rural	33 (14.5)	64 (28.2)	97 (42.7)	0.9 (0.549–1.673)	0.9 (0.438–2.218)
Parity
Primiparous	9 (4.0)	14 (6.1)	23 (10.1)	1	1
Multiparous	13 (5.7)	29 (12.8)	42 (18.5)	1.4 (0.496–4.150)	2.8 (0.714–5.210)
Grand Multiparous	54 (23.8)	108 (47.6)	162 (71.4)	1.3 (0.523–3.159)	1.9 (0.591–6.372)
ANC follow up
Yes	59 (26.0)	117 (51.5)	176 (77.5)	1	1
No	17 (7.5)	34 (15.0)	51 (22.5)	1.01 (0.521–1.953)	3.2 (1.483–6.940) *
Number of ANC follow up (n = 176)
≤ 2 times	37 (16.3)	45 (19.8)	82 (36.1)	1	1
≥ 3 times	22 (9.7)	72 (31.7)	94 (41.4)	2.7 (1.411–5.133)	3.3 (1.608–6.589) *
Duration of labor
< 24 hours	35 (15.4)	75 (33.1)	110 (48.5)	1.2 (0.665–2.009)	1.1 (0.475-2.300)
≥ 24 hours	41 (18.0)	76 (33.5)	117 (51.5)	1	1
Duration of rupture of membrane
< 24 hours	59 (26.0)	83 (36.6)	142 (62.6)	2.4 (1.224–4.646)	4.6 (1.933–11.028) *
≥ 24 hours	17 (7.5)	68 (29.9)	85 (37.4)	1	1
Number of pelvic examinations
< 5 times	71 (31.3)	116 (51.1)	187 (82.4)	1	1
≥ 5 times	5 (2.2)	35 (15.4)	40 (17.6)	4.3 (1.604–11.444)	12.1 (2.873–19.131) *
Mode of delivery
Spontaneous vaginal delivery	49 (21.6)	115 (50.6)	164 (72.2)	1
Instrumental delivery	20 (8.8)	17 (7.5)	37 (16.3)	0.4 (0.175–0.750)	0.2 (0.049–0.493) *
Cesarean section	7 (3.1)	19 (8.4)	26 (11.5)	1.2 (0.457–2.928)	1.1 (0.301–4.077)
Episiotomy
Yes	39 (17.2)	54 (23.8)	93 (41.0)	1	1
No	37 (16.3)	97 (42.7)	134 (59.0)	1.9 (1.082–3.313)	2.1 (1.009–4.488)
Place of delivery
Home	14 (6.2)	17 (7.5)	31 (13.7)	0.6 (0.260–1.212)	0.5 (0.181–1.580)
Hospital	62 (27.3)	134 (59.0)	196 (86.3)	1	1
Any previous bad obstetric history
Yes	18 (7.9)	28 (12.4)	46 (20.3)	1	1
No	58 (25.5)	123 (54.2)	181 (79.7)	1.4 (0.698–2.663)	1.8 (0.614–5.557)
Referral status
Yes	14 (6.2)	24 (10.5)	38 (16.7)	1	1
No	62 (27.3)	127 (56.0)	189 (83.3)	1.2 (0.578–2.469)	2.5 (0.936–6.503)
Hypertension
Yes	20 (8.8)	28 (12.3)	48 (21.1)	0.6 (0.331–1.227)	1.5 (0.587–3.882)
No	56 (24.7)	123 (54.2)	179 (78.9)	1	1
Diabetic mellitus
Yes	25 (11.0)	21 (9.3)	46 (20.3)	0.3 (0.170–0.640)	0.4 (0.166–0.990)
No	51 (22.5)	130 (57.2)	181 (79.7)	1	1
Sexual transmitted infection
Yes	29 (12.8)	37 (16.3)	66 (29.1)	0.5 (0.291–0.952)	0.7 (0.310–1.803)
No	47 (20.7)	114 (50.2)	161 (70.9)	1	1
Anemia
Yes	58 (25.5)	63 (27.8)	121 (53.3)	0.2 (0.120–0.413)	0.3 (0.122–0.615)
No	18 (7.9)	88 (38.8)	106 (46.7)	1	1
*P Value < 0.05

The present study investigated the determinants of puerperal sepsis among mothers who gave birth at Jigjiga public hospitals in Eastern Ethiopia. The results indicate that being married, having primary education, being grand multiparous, not attending antenatal care (ANC), having fewer than three ANC follow-ups, and having membranes rupture for 24 hours or more are all independent predictors of puerperal sepsis.

The results showed that married mothers were more likely to develop puerperal sepsis compared to divorced mothers. This may be due to the fact that married women may be more likely to have a higher parity, which is a known risk factor for puerperal sepsis. This finding is supported by a study in Nigeria [14]. Similarly, mothers with primary education were more likely to develop puerperal sepsis compared to those with no formal education, which is consistent with a study conducted in Ethiopia [15, 16]. The results also revealed that grand multiparous women were more likely to develop puerperal sepsis compared to primiparous women. This may be due to the fact that grand multiparous women may be more likely to experience placental abruption, placenta previa, and other complications that increase their risk of developing puerperal sepsis. This is consistent with previous study conducted in Ethiopia [17] and Nepal [18].

The study also found that women who did not attend antenatal care (ANC) were more likely to develop puerperal sepsis compared to those who attended ANC. ANC attendance is an important indicator of the quality of prenatal care, and women who do not attend ANC may be more likely to experience complications during pregnancy and childbirth. This is in line with previous research conducted in Ethiopia [19]. Similarly, the finding that women who had fewer than three ANC follow-ups were three times more likely to develop puerperal sepsis compared to those who had three or more ANC follow-ups suggests that frequent ANC attendance is an important factor in reducing the risk of puerperal sepsis. Women who had fewer than five times pelvic examinations were twelve times more likely to develop puerperal sepsis. This suggests that inadequate prenatal care and lack of provider-patient interaction may contribute to the development of puerperal sepsis. This is consistent with a study conducted in Uganda [20]. The study also found that women whose membranes ruptured for less than 24 hours were more likely to develop puerperal sepsis compared to those whose membranes ruptured for 24 hours and more. This is supported by previous research conducted in Kenya [21].

The study found that mothers who underwent episiotomy were two times more likely to develop puerperal sepsis compared to those who did not undergo the procedure. Episiotomy can cause lacerations and trauma to the perineum, which can provide a portal of entry for bacteria and increase the risk of infection. This finding is consistent with previous study in Ethiopia [22, 23]. The study also found that mothers who did not have a previous bad obstetric history were two times more likely to develop puerperal sepsis compared to those who had a previous bad obstetric history. This may be because women who have had previous complications during pregnancy or childbirth may be more aware of their risk factors and take steps to prevent complications during subsequent pregnancies, such as seeking antenatal care and delivering in a hospital setting. This is consistent with the study conducted in Kenya[21] and India [24]. Moreover, the study found that mothers who were not referred were three times more likely to develop puerperal sepsis compared to those who were referred. This suggests that delayed or inadequate referral for medical attention may contribute to the development of puerperal sepsis. This finding is supported by a study conducted in Uganda [25], and Ethiopia [26].

The present study identified several significant determinants of puerperal sepsis among mothers who gave birth at Jigjiga public hospitals in Somali Regional State, Eastern Ethiopia. The analysis of this study indicated that not attending antenatal care regularly, having fewer antenatal care follow-ups, membranes rupturing for less than 24 hours, having fewer pelvic examinations, undergoing episiotomy, not having a previous bad obstetric history, being not referred for further care, and having hypertension were all identified as determinants of puerperal sepsis. Healthcare providers and policymakers should prioritize improving access to quality antenatal care, enhancing maternal education and empowerment, and implementing evidence-based guidelines for managing obstetric complications. Furthermore, community-based education campaigns should be implemented to raise awareness about the importance of antenatal care and proper hygiene practices during childbirth.

AOR

Adjusted Odds Ratio

ANC

Antenatal Care

Confidence Interval

EDHS

Ethiopia Demographic and Health Survey

IRB

Institutional Review Board

Odds Ratio

SPSS

Statistical Package for the Social Sciences

WHO

World Health Organization

Ethical Considerations

This study was approved by the by the Institutional Review Board (IRB) of Jigjiga University, Jigjiga, Eastern EthiopIa [HRERC/088/2022]. Written permission was secured from the relevant authorities of the study settings, including Sultan Sheik Hassan Yabare Comprehensive Specialized Hospital and Karamara General Hospital. Informed consent was obtained from all participants prior to data collection. For participants under 18 years of age, written assent was obtained from their and consent from their guardian. The data collectors were instructed to maintain patient confidentiality throughout the data collection process. To ensure the confidentiality of participants, personal identifiers such as names were not used, and codes were employed instead. Participants were informed of their right to refuse or terminate participation at any point during the interview.

Consent for Publication

No applicable.

Availability of Data and Materials

The datasets generated and analyzed during the current study are available from the corresponding authors upon reasonable request.

Competing Interests

The authors declare that they have no competing interests regarding the conduct of this study or the publication of its findings.

Funding

This research did not receive any specific grant from funding for the publication of this article.

Authors' Contributions

H.N.A., A.A.T., M.A.M., and A.M.I. Conceptualization of the study, methodology, data collection, performed statistical analysis, interpretation and drafted the manuscript. F.I.D., T.G., and C.D.U provided critical insights and revisions to the final manuscript. All authors reviewed and approved the final version prior to submission.

Acknowledgment

The authors would like to express their gratitude to the health workers at Jigjiga public hospitals for their invaluable support during data collection. We also acknowledge the study participants for their willingness to share their experiences and contribute to this research.

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No competing interests reported.

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Determinants of puerperal sepsis among mothers who give birth at Jigjiga public hospitals, Somali Regional State, Eastern Ethiopia

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Version 1

Abstract

INTRODUCTION

METHODS

Study Design, Period and Setting

Study Population

Eligibility Criteria

Sample Size Determination

Sampling Procedure

Data Collection Tool and Procedure

Data Quality Control

Data Analysis

RESULTS

Sociodemographic Characteristics of the Study Participants

Obstetric Characteristics of the Study Participants

Determinants of puerperal sepsis

DISCUSSION

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1