Determinants of Puerperal Sepsis Among Postpartum Women at Public Hospital in Gedeo Zone, Southern Ethiopia, 2023: Unmatched Case-Control Study

doi:10.21203/rs.3.rs-5040733/v1

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Research Article

Determinants of Puerperal Sepsis Among Postpartum Women at Public Hospital in Gedeo Zone, Southern Ethiopia, 2023: Unmatched Case-Control Study

https://doi.org/10.21203/rs.3.rs-5040733/v1

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Introduction: The World Health Organization records 295,000 maternal deaths during childbirth each year, of which 15% are due to postpartum sepsis. In Ethiopia, it is the third cause of maternal death after hemorrhage and hypertension. However, data on the determinants of puerperal sepsis in the study area is scarce.

Objective: This study aimed to identify determinants of puerperal sepsis among postpartum women at a public hospital in Gedeo Zone, southern Ethiopia, in 2023.

Methods: A hospital-based, unmatched case-control study was conducted among 475 postpartum women (119 cases and 356 controls with a ratio of 1:3) at public hospitals in the Gedeo Zone from July 1 to September 20, 2023. All cases were included, and Systematic random sampling was employed to select controls. A pretested and structured face-to-face interview questionnaire was conducted. Data were entered cleared and edited using EPI-data software 4.6and then exported to Statistical Package for Social Science version 26 for analysis. Binary logistic analysis was executed, and all variables with a p-value of <0.25 were entered into multivariable logistic regression. Finally, multivariable logistic regression analysis was employed to identify independent determinants of puerperal sepsis. A P-value of >0.05 at the 95% CI was considered the cut-off point to declare a statistically significant association.

Result: Four hundred seventy-five (119 cases and 356 controls) were included in this study with a 98.96% response rate.Variables identified as significantly associated with puerperal sepsis were no ANC follow-up (AOR = 4.19, 95% CI (2.32, 7.58), cesarean section (AOR = 2.74, 95% CI (1.19, 6.31), postpartum hemorrhage (AOR=2.57, 95% CI (1.39, 4.74), duration of rupture of membrane ≥ 24 hours (AOR=3.31, 95% CI(1.89, 5.83), duration labor ≥ 24 hours (AOR=3.15 95% CI(1.09, 8.43), and anemia (AOR=2.46, 95% CI (1.39, 4.32).

Conclusion: In this study, variables significantly associated with puerperal sepsis were the absence of antenatal care, cesarean section, postpartum hemorrhage, prolonged PROM, duration of labor ≥ 24 hours, and anemia. Puerperal sepsis caused by these factors should be minimized by following labor management protocol and emphasizing information on dietary diversification.

Puerperal sepsis

postpartum women

Determinant

Public Hospital

Gedeo Zone

Puerperal sepsis is defined as an infection of the genital tract that can develop up to six weeks after delivery and can happen at any point following the rupture of the membranes. It is accompanied by two or more of the following symptoms: pelvic pains, elevated body temperature (38.5°C), atypical vaginal discharge, unpleasant discharge odor, and a delay in the uterus's size decrease (2 cm per day in the first eight days) (1)

The World Health Organization (WHO) reported that puerperal sepsis accounts for 15% of the approximately 295,000 maternal fatalities that occur each year during labor and delivery (2). An estimated 62,000 maternal fatalities are attributed to maternal sepsis, with up to 5.2 million new cases reported each year (3). The major causes of puerperal sepsis are bilateral tubal blockage, infertility, acute or chronic pelvic inflammatory illness, and maternal fatalities (4). Puerperal sepsis is among the leading causes of preventable maternal morbidity and mortality not only in developing countries but also in developed countries which accounts for 10.7% and 4.7% of maternal deaths respectively (5). It is placed sixth among women of reproductive age in terms of illness burden, depression, HIV/AIDS, tuberculosis, abortion, and schizophrenia (3).

In Sub-Saharan Africa, maternal mortality due to puerperal sepsis increased from 9.7% in 2009 (6) to 10.3% in 2014 (5). Puerperal sepsis was the cause of maternal mortality in retrospective research from Mbarara, Uganda, accounting for 30.9% of maternal deaths. Postpartum hemorrhage came in second at 21.6% (7). A study conducted in Tanzania showed that the prevalence of puerperal sepsis was 11.5% (8).

In Ethiopia, puerperal sepsis is the third direct primary cause of maternal death after hemorrhage and hypertension (9, 10). According to a Gonder Referral Hospital study, puerperal sepsis occurred in 17.2% of women during childbirth and the postpartum period (11). Puerperal sepsis was the fourth most common cause of maternal deaths in Ethiopia, accounting for 13% of all maternal deaths, according to another study on maternal mortality (12).

The researchers identified several risk factors associated with puerperal sepsis, including age > 30 years, lack of antenatal care follow-up, mode of placental removal, a referral from other health institutions, anemia, delivery by cesarean section, premature rupture of the membrane, prolonged labor, frequent vaginal examinations with poor hygiene and poor aseptic technique, postpartum hemorrhage, lack of formal education, and low income (13, 14).

To prevent infections related to labor and delivery, the WHO technical group suggests using antibiotics for C/S, PPROM, third- or fourth-degree perineal tears, manual placenta removal, and operative vaginal births; additionally, antimicrobial use during vaginal and C/S deliveries and per-vaginal examination should be performed every four hours (15). Similarly, the World Health Organization suggests that to lower the number of maternal mortality, no woman in a health facility should develop puerperal sepsis (16).

Despite this, puerperal sepsis is one of the causes of maternal death in Ethiopia, which ranks among the nations with the highest rates of maternal mortality. At an estimated 412 deaths per 100,000 live births, the maternal mortality rate is still high, according to the Ethiopian Demographic and Health Survey 2016 (EDHS) (17). As part of the Sustainable Development Goals (SDGs), every country should reduce the maternal mortality ratio to 70 per 100,000 by 2030 (18). Ethiopia's Health Sector Transformation Plan (HSTP II) aims to reduce the country's maternal mortality rate from 401 per 100,000 live births to 279 per 100,000 live births between 2020–2021 and 2024–2025 (19).

To reach our country's SDG and HSTP II plan targets, it is better to identify the causes and contributing factors for developing puerperal sepsis, which is very important to reduce maternal morbidity and mortality. Although puerperal sepsis is among the leading causes of maternal mortality, there has been a scarcity of studies conducted to investigate the determinants of puerperal sepsis in this study area. Furthermore, this study incorporates additional variables not previously examined in Ethiopia. Previous research conducted in other countries has linked obstructed labor, multiple pregnancies, and post-term pregnancy to cases of puerperal sepsis (20–23). Therefore, this study aimed to identify determinants of puerperal sepsis among postpartum women who got service at public hospitals in the Gedeo Zone.

4.1. Study Area and Period

A study was conducted in Gedeo Zone in four Government hospitals from July 1 to September 20, 2023. Gedeo Zone is one of the zones found in the Southern Nations, Nationalities, and Peoples Region (SNNPR), with the administrative center of Dilla Town located 370 km from Addis Ababa and 86 km from the regional city Hawassa. Based on the 2022 annual report of the Gedeo Zone health department, the estimated number of mothers of reproductive age is 256,487, and the estimated number of deliveries is 43,178. In the Gedeo Zone, the skilled delivery rate is 50%. The zonal coverage for ANC 4 was 58%, and postnatal care was 80%. The zone has one referral teaching hospital, three primary hospitals, 38 health centers, 149 health posts, nine nongovernmental organizations, one private hospital, and more than 27 private clinics. All hospitals provide comprehensive emergency obstetric care services (24).

4.2. Study Design

The study design was a hospital-based un-matched case-control study design.

4.3. Population of the Study

4.3.1. Source population

All postpartum women got services at a public hospital in the Gedeo Zone within 42 days of delivery.

4.3.2. Study population

Cases: All postpartum women who got services at a public hospital in Gedeo Zone within 42 days of delivery were diagnosed with puerperal sepsis during the data collection period.

Controls: postpartum women who got services at a public hospital in Gedeo Zone within 42 days of delivery without puerperal sepsis were selected during the data collection period.

4.4 Eligibility Criteria

4.4.1 Inclusion criteria for cases

Postpartum women got services at a public hospital in Gedeo Zone within 42 days of delivery from July 1 to September 20, 2023, diagnosed with puerperal sepsis.

4.4.2 Inclusion criteria for controls

Postpartum women who got services at a public hospital in Gedeo Zone within 42 days of delivery from July 1 to September 20, 2023, are not diagnosed with puerperal sepsis.

4.4.3 Exclusion criteria for cases

Postpartum women, those who were in the intensive care unit to the extent that they were unable to communicate until the end of the study period, and women with diseases such as hepatitis infection and malaria, were excluded from the study. Those selected participants came the second time to avoid repetition.

4.4.4 Exclusion criteria for controls

Those who were unable to speak, hear, and come for the second time in the study period.

4.5. Sample Size and Sampling Methods

4.5.1. Sample Size Determination

The sample size was determined using an unmatched case-control study in EPI Info software version 7. Considering the assumption that the ratio of cases to controls was 1:3, 95% CI, 80% power of the study, the AOR was 3.43, and the proportion of exposed controls was 4.13%. Taking the prolonged labor associated with puerperal sepsis from the recent study conducted in Hawassa City (23) was given 436 total sample size (109 cases and 327 controls), and by adding a 10% non-response rate, the final sample size was 480 (120 cases and 360 controls).

Table 1 Sample size determination for determinants of puerperal sepsis among postpartum women at Public Hospital in Gedeo Zone, Southern Ethiopia, 2023.

S. No	Variables	% control exposed	AOR	Ratio	Sample size with a 10% non-response rate	Reference
1	Duration of PROM	16	3.73	1:3	154	(Demisse et al., 2019)
2	Rural residence	28.6	2.5	1:3	260	(Demisse et al., 2019)
3	Delivery by C/S	16.4	3.5	1:3	250	(Tesfaye et al., 2023)
4	Prolonged labor	4.13	3.43	1:3	480	(Tesfaye et al., 2023)

4.5.2. Sampling Technique

All four public hospitals in the Gedeo Zone were included in the study. The sample size was proportionally allocated to each hospital based on the client flow in the previous three months. All women diagnosed with puerperal sepsis by physicians during the data collection period in each hospital were selected as cases (due to the rare cases). Women without puerperal sepsis who met the inclusion criteria were selected using systematic random sampling techniques as controls and interviewed during the study period. Based on the average number of postpartum women who were getting postnatal care service (admitted to the gynecology ward and getting postnatal care service) in four hospitals in the previous six months reported, an average of 1689 nonpuerperal sepsis postpartum women and 146 diagnosed with puerperal sepsis were expected. The expected numbers for each hospital were as follows: Dilla University Referral Hospital (DURH) was 64, Cheffe Primary Hospital (CPH) was 38, Gedeb Primary Hospital (GPH) was 26, and Bule Primary Hospital (BPH) was 18. All postpartum women diagnosed with puerperal sepsis were selected as a case until the required sample size was achieved, and three controls for each case were selected using systematic sampling. The first Control women were selected randomly, then continued every 5th interval since k = 1689/360 = 5 (Figure 1).

Figure 1. Schematic presentation of the sampling procedure to determinants of puerperal sepsis among postpartum women at a public hospital, in Gedeo Zone

4.6. Study Variables

4.6.1 Dependent variable

Puerperal sepsis is a dummy variable that takes a value of one if the respondent is disease and zero otherwise.

4.6.2 Independent Variables

Socio-demographic characteristics: Age, Residence, educational status, maternal occupation).

Obstetrics factors: Parity, multiple pregnancies, Mode of delivery, prolonged labor, Premature Rupture of Membrane, frequent vaginal examination, Hx of ANC follow-up, preeclampsia, postpartum hemorrhage, obstructed labor, and Post-term birth).

Maternal Medical factors: Gestational diabetes mellitus, Anemia, sexually transmitted infection, and HIV status).

Health-related factors: referral status, Hygienic practice, and Attendant during delivery).

4.7. Operational and Term Definitions

Puerperal sepsis is an infection of the genital tract that can happen at any point between the 24-hour mark following birth and the 42nd day postpartum, and it is characterized by the presence of two or more of the following symptoms: pelvic pain, Fever, defined as a fever of 38°C or above at any time, pungent vaginal discharge, and a delay in the uterus's pace of shrinkage (less than 2 cm/day for the first eight days) (1).

Cases: Postpartum mothers admitted to the ward or coming to the postnatal clinic to the selected hospitals during the study period who were diagnosed with puerperal sepsis by physicians working in maternity wards selected as cases (16).

Controls: Postpartum mothers admitted to or coming to the postnatal clinic in the selected hospitals during the study period who have no puerperal sepsis in their medical records were enrolled as controls. As soon as the cases were diagnosed, three controls were chosen on the same day from the same hospital for each case.

Prolonged premature rupture of membrane: the amniotic membrane ruptures for longer than 24 hours.

Prolonged labor: in cases where labor lasts more than 24 hours, as the start of regular, rhythmic, painful contractions followed by cervical dilatation (25).

Gestational diabetes mellitus: postpartum women were considered as having GDM when their fasting plasma glucose is ≥ 126 mg/ dl, two-hour plasma glucose after taking 75g oral glucose, and random plasma glucose is ≥ 200 mg/ dl with the presence of symptoms of DM and was taken from their medical cards (26).

Anemia: postpartum women were considered as having Anemia their hemoglobin level of <11 g / dl was taken from their medical cards(27, 28).

4.8. Data Collection Methods

A structured, face-to-face interview questionnaire was adapted from different literature and was used to collect data from the study participants (29, 30). The questionnaire was written in the English language following a thorough assessment of previously verified published research. Then, the questionnaire was translated into Amharic, and the data collector used the Amharic version of the questionnaire to collect data from the study participants. Again, it was translated back into English for analysis. Data were collected by ten midwiferies and supervised by two health Officers. Furthermore, patient cards were reviewed to collect information on obstetric and medical characteristics, and data on maternal socio-demographic characteristics and other factors that can't be obtained from their medical cards were collected from the women by using an interviewer.

4.9. Data Quality Management

Data collectors and supervisors were trained for two days in data-gathering processes. The questionnaire was designed and written in English first, then translated into Amharic by language experts, and finally back to English to ensure consistency. The data was collected in the Amharic version. Before the data was collected, a pre-test was done on 5% (6 cases and 18 controls) of the postpartum mothers admitted to Chuko Hospital. Daily investigator evaluated and checked the obtained data for completeness and consistency.

4.10. Data Management and Analysis

The data were coded, entered, cleaned, and stored in epi-data version 4.6. Frequency distributions were used to check for missing data. Categorical variables were expressed as frequencies and percentages. Cross tabulations of independent variables with the occurrence or experience of puerperal sepsis were performed. A binary logistic regression model was used to see the association between independent and dependent variables. The fitness of logistic regression models was assessed using the Hosmer-Lemeshow test, and its p-value is 0.306. A Multicollinearity test was carried out to see the correlation between each independent variable, using the Variance Inflation Factor (VIF) and a tolerance test, and there were no variables that did not meet the criteria. Variables with a P-value of < 0.25 in bivariable analysis were candidates for multivariable analysis. In the final model, variables with a P-value <0.05 were used to declare them as statistically significant. The odds ratio (OR) with a 95% confidence interval was used to measure the strength of the association.

4.11. Ethical Clearance

The research proposal was approved by the Institutional Research Ethical Review Committee (Ref.No; IRERC/031/23) of Madda Walabu University, Shashemene Campus, and the Public Health Department of Postgraduate Study. Based on the approval, an official supporting letter was obtained from the Department of Public Health and submitted to the South Nation Nationality and People Region Health Office. A supporting letter was also taken from the South Nation Nationality and People Region Public Health Institute and given to the Gedeo Zone Health Department. Again, a permission letter was taken from the Gedeo Zone Health Department and given to the medical directors of each hospital. The purpose of the study, risks, and benefits of the study were explained to the participants. Verbal and written consent was taken from the participants before data collection started. The confidentiality of the information was maintained by omitting their names and personal identification.

4.12. Dissemination Plan

Finally, the findings of the study were submitted to Madda Walabu University, Shashemene Campus, and the Public Health Department of Postgraduate Study. It will be presented at the last defense. It will also be communicated to the Gedeo Zone health department. Further efforts will be made to publish in national and international peer-reviewed journals.

5.1 Socio-demographic Characteristics

Out of the total sample size of 480, 475 postpartum women (119 cases and 356 controls) were included in the analysis, resulting in a response rate of 98.96%. The age of respondents ranges from 16 to 48 years, with a mean age of 28.21 ± 5.954 for both case and control groups. Thirty-seven percent of cases and 111 (31.92%) of the control respondents were in the age group of 25–31 years. The majority of the control group 207 (58.1%) and 50 (42.0%) of the cases were urban residents. Concerning educational status, 48 (40.3%) of cases and 98 (27.5%) of controls had no formal education. Regarding occupational status 57 (49.9%) of the cases and 134 (37.6%) of the control group were housewives ( Table 2).

Table 2

Socio-demographic characteristics of respondents on postpartum mothers at a public hospital in Gedeo zone, 2023.
Variable		Puerperal sepsis status		Total N (%)
Variable		Case N (%)	Control N (%)	Total N (%)
Age	16–25	36 (30.3)	128 (36.0)	164 (34.5)
	25–31	44 (37.0)	111 (31.2)	155 (32.6)
	≥ 32	39 (32.8.9)	117(32.9)	156 (32.8)
Residence	Urban	50 (42.0)	207 (58.1)	257 (54.1)
Residence	Rural	69 (58.0)	149 (41.9)	218 (45.9)
Mother’s education	No formal education	48 (40.3)	98 (27.5)	146 (30.7)
	Primary	26 (21.8)	104 (29.2)	130 (27.4)
	Secondary	23 (19.3)	92 (25.8)	115 (24.2)
	College and above	22 (18.5)	62 (17.4)	84 (17.7)
The educational status of her husband	No formal education	33 (31.1)	95 (26.7)	132 (28.4)
	Primary	35 (29.4)	106 (29.8)	141 (29.7)
	Secondary	31 (26.1)	95 (26.7)	126 (26.5)
	College and above	16 (13.4)	60 (16.9)	76 (16.0)
Marital Occupation	House-wife	57 (49.9)	134 (37.6)	191 (40.2)
	Self-employed	31 (26.1)	101 (28.4)	132 (27.8)
	Government employer	21 (17.6)	78 (21.9)	99 (20.8)
	others*	10 (8.4)	43 (12.1)	53 (11.2)

Table 2 Socio-demographic characteristics of respondents on postpartum mothers at a public hospital in Gedeo zone, 2023.

5.2. Obstetric Characteristics

With regards to ANC follow-up, 68 (57.1%) cases and 80 (22.5%) controls were reported as they have no ANC follow-up. Among the participants, 28 (23.5%) cases and 74 (20.8%) controls were Primipara. Almost all, 311 (87.4%), controls delivered in health institutions. Forty-eight (40.3%) cases and 58 (16.3%) controls had a postpartum hemorrhage. Among the mothers, 18 (15.1%) cases had multiple pregnancies.

The majority of participants in the study (72.3% cases, 82.5% controls) had term gestation, and episiotomies were performed on only 31 (26.1%) of cases and 78 (21.9%) of controls.

Of the postpartum mothers included in the study, 70 (58.8%) of the cases and 75 (21.1%) of the controls had a Duration of labor ≥ 24 hours (Table 3).

Table 3

Obstetric characteristics of postpartum women at Gedeo zone public hospitals, Southern Ethiopia, 2023.
variable		Puerperal sepsis status		Total N (%)
variable		Case N (%)	Control N (%)	Total N (%)
Parity	Primipara	28 (23.5)	74 (20.8)	102 (21.5)
	Multipara	55 (46.2)	195 (54.8)	250 (52.6)
	Grand multipara	36 (30.3)	87 (24.4)	123 (25.9)
ANC follow up	Yes	51 (42.9)	276 (77.5)	327 (68.8)
ANC follow up	No	68 (57.1)	80 (22.5)	148 (31.2)
Number of ANC follow-up	≤ 2 times	24 (51.1)	148 (53.6)	172 (53.3)
Number of ANC follow-up	≥ 3 times	23 (48.9)	128 (46.4)	151 (46.7)
Place of delivered	Home	29(24.4)	45 (12.6)	74 (15.6)
Place of delivered	Health institutions	90 (75.6)	311 (87.4)	401 (87.4)
Prophylaxis antibiotic used	no	86 (72.3)	275 (77.2)	361 (76.0)
Prophylaxis antibiotic used	yes	33 (27.7)	81 (22.8)	114 (24.0)
Gestational age	Preterm	12 (10.1)	22 (6.2)	34(7.2)
	Term	86 (72.3)	193(82.5)	378 (79.6)
	post term	21 (17.6)	42 (11.8)	63 (13.3)
multiple pregnancies	Yes	18(15.1)	46(12.9)	64 (13.5)
multiple pregnancies	No	101 (84.9)	310 (87.1)	411 (86.5)
obstructed labor	Yes	19 (16.0)	29 (8.1)	48 (10.1)
obstructed labor	No	100 (84.0)	327 (91.9)	427(89.9)
Duration of labor	< 12hrs	6 (5.0)	31 (8.7)	37 (7.8)
	12–24 hrs	43 (36.1)	250 (70.2)	293 (61.7)
	≥ 24 hrs	70 (58.8)	75 (21.1)	145 (30.5)
labor started	Spontaneous	95 (79.8)	298 (83.7)	393(82.7)
labor started	Induction	24 (20.2)	58 (16.3)	82 (17.3)
Episiotomy done	Yes	31(26.1)	78 (21.9)	109 (22.9)
Episiotomy done	No	88 (73.9)	278 (78.1)	366 (77.1)
PPH	yes	48 (40.3)	58 (16.3)	106(22.3)
PPH	No	71 (59.7)	298 (83.7)	369 (77.7)
preeclampsia	Yes	31 (26.1)	65 (18.3)	96 (20.2)
preeclampsia	No	88 (73.9)	291 (81.3)	379 (79.8)

Table 3 Obstetric characteristics of postpartum women at Gedeo zone public hospitals, Southern Ethiopia, 2023.

Among the postpartum women included in the study, 74 (62.2%) of the cases and 264 (74.2%) of the controls were SVD, whereas 39 (32.8%) of the cases and 47 (13.2%) of the control groups were by cesarean section delivered (Fig; 2).

Figure 2 Mode of delivery of postpartum women at Gedeo Zone public hospitals, Southern Ethiopia, 2023

Of the study participants, 39 (32.8%) cases and 101 (28.4%) controls followed the number of per-vaginal examinations greater than or equal to five times. Fifty-six (47.1%) of cases and 181 (50.8%) controls followed the number of per-vaginal examinations less than five times (Fig. 3).

Figure 3 Frequency of per-vaginal examination postpartum women at Gedeo Zone public hospitals, Southern Ethiopia, 2023

When we see the duration of premature rupture of the membrane among the study participants, about 65 (54.6%) of the cases had PROM ≥ 24 hrs, and the majority (75.3%) of the controls had PROM < 24 hrs (Fig; 4).

Figure 4 Duration of PROM of postpartum women at Gedeo zone public hospitals, Southern Ethiopia, 2023.

5.3. Medical or Co-morbidities of the Mothers

With regards to the medical characteristics of the study participants, 12 (10.1%) of the cases and 19 (5.3%) of the controls had Gestational diabetes mellitus. Similarly, 53 (44.5%) of the cases and 92 (25.8%) of the controls were anemic (Table 4)

Table 4

Medical problems among postpartum mothers in Gedeo Zone at public hospital, 2023.
Variable		Puerperal sepsis status		Total N (%)
Variable		Case N (%)	Control N (%)	Total N (%)
HIV	yes	30 (25.2)	109 (30.6)	139 (29.3)
HIV	no	89 (74.8)	247 (69.4)	336 (70.7)
GDM	yes	12 (10.1)	19 (5.3)	31 (6.5)
GDM	no	107 (89.9)	337 (94.7)	444 (93.5)
STI	yes	45(37.8)	133(37.4)	178(37.5)
STI	no	74 (62.2)	223 (62.6)	297 (62.5)
Anemia status	Anemic	53 (44.5)	92 (25.8)	145 (30.5)
Anemia status	Non anemic	66 (55.5)	164 (74.2)	330 (69.5)

Table 4 Medical problems among postpartum mothers in Gedeo Zone at public hospital, 2023.

5.4. Health facility-related factors

More than half (53.8%) of cases and 222 (62.5%) of control women observed a person assisting them using only gloves. Around 31 (26.1%) of cases and 83 (23.3%) of control women observed a person assisting them in washing their hands and using gloves. Among the participants, 101 (84.9%) of case and 333 (93.5%) control had Assisted during delivery. Out of them, 55 (54.5%) cases and 149 (44.7%) control delivered by health professionals (Table 5)

Table 5

Health-facility related characteristics of postpartum women in Gedeo Zone at public hospital, 2023.
Variable		Puerperal sepsis status		Total N (%)
Variable		Case N (%)	Control N (%)	Total N (%)
referred status	yes	47 (39.5)	133 (37.4)	180 (37.9)
referred status	no	72 (60.5)	223 (62.6)	295 (62.1)
Assisted during delivery	Yes	101 (84.9)	333 (93.5)	434 (91.4)
Assisted during delivery	No	18 (15.1)	23 (6.5)	41 (8.6)
Birth attendant	health work	55 (54.5)	149 (44.7)	204 (47.0)
Birth attendant	TBA	46 (45.5)	184 (55.3)	230 (53.0)
hygienic practice	none	24 (20.2)	51 (14.3)	75 (15.8)
	used glove	64 (53.8)	222 (62.4)	286 (60.2)
	used gloves and washed hands	31 (26.1)	83 (23.3)	114 (24.0)

Table 5 Health-facility related characteristics of postpartum women in Gedeo Zone at public hospital, 2023.

5.5. Determinants of puerperal sepsis among postpartum women

In bi-variable logistic regression analysis, place of delivery, mode of delivery, ANC follow-up, Duration of premature rupture of membrane, Duration of labor, assisted delivery, gestational diabetes mellitus, obstructed labor, preeclampsia, postpartum hemorrhage, and anemia showed association with puerperal sepsis (P < 0.25). After applying multivariable logistic regression mode of delivery, ANC follow-up, Duration of premature rupture of membrane, Duration of labor, postpartum hemorrhage, and anemia were associated (significant at p < 0.05) with puerperal sepsis (Table 6).

Table 6

Bivariable & multivariable logistic regression result for the determinants of puerperal sepsis among postpartum women at Gedeo Zone public hospitals, Southern Ethiopia, 2023
Variable		Puerperal sepsis status		OR (95% CI)		P-value
Variable		Cases N (%)	Controls N (%)	COR(95%CI)	AOR(95%CI)	P-value
Residence	urban	50 (42.0)	207 (58.1)	1	1
Residence	rural	69 (58.0)	149 (41.9)	1.92(1.26–2.92)	1.79 (.92-3.48)	0.068
ANC follow-up	yes	51 (42.9)	276 (77.5)	1	1
ANC follow-up	no	68 (57.1)	80 (22.5)	4.60(2.96–7.14)	4.19 (2.32–7.58)**	< 0.001
Duration of labor	< 12hrs	6(5.0)	31 (8.7)	1	1
	12–24 hrs	43 (36.1)	250(70.2)	.89(0.35–2.25)	.59 (0.19–1.78)	0.325
	≥ 24 hrs	70(58.8)	75 (21.1)	4.82 (1.89–12.25)	3.15 (1.09–9.43)*	0.041
PROM	< 24 hrs	54 (45.4)	268 (75.3)	1	1
PROM	≥ 24 hrs	65 (54.6)	88 (24.7)	3.66(2.37–5.65 )	3.31 (1.89–5.83)**	< 0.001
Assisted during delivery	yes	101 (84.9)	333 (93.5)	1	1
Assisted during delivery	no	18 (15.1)	23 (6.5)	2.58(1.34–4.97)	2.31 (0.88–6.06)	0.090
Mode of delivery	SVD	74 (62.2)	264 (74.2)	1	1
	C/S	39 (32.8)	47 (13.2)	2.96 (1.80–4.87)	2.74(1.19–6.31)*	0.018
	Instrumental	6 (5.0)	45 (12.6)	.48 (0.19–1.16)	.37(0.12–1.15)	0.080
Place of delivery	home	29(24.4)	45 (12.6)	2.23(1.32–3.75)	.89 (.39-2.03)	0.748
Place of delivery	Institutional	90 (75.6)	311 (87.4)	1	1
obstructed labor	Yes	19 (16.0)	29 (8.1)	2.14(1.15–3.98)	1.17(0.52–2.65)	0.629
obstructed labor	No	100 (84.0)	327 (91.9)	1	1
PPH	No	71 (59.7)	298 (83.7)	1	1
PPH	Yes	48 (40.3)	58 (16.3)	3.47(2.19–5.51)	2.57 (1.39–4.74)**	0.003
preeclampsia	Yes	31 (26.1)	65 (13.2)	1.57 (0.97–2.57)	.94(0.49–1.82)	0.969
preeclampsia	No	88 (73.9)	291 (81.7)	1	1
GDM	Yes	12 (10.1)	19 (5.3)	1.99(.93-4.23)	1.72 (0.67–4.44)	0.289
GDM	No	107 (89.9)	337 (94.7)	1	1
Anemia of mother	Non an	66 (55.5)	264 (74.2)	1	1
Anemia of mother	anemic	53 (44.5)	92 (25.8)	2.30(1.49–3.55)	2.46(1.39–4.32)**	0.002

In this study, the odds of developing puerperal sepsis among postpartum women with no ANC follow-up were 4.19 times higher than postpartum women who had attended ANC follow-up (AOR = 4.19; 95% CI: 2.32–7.58).

Accordingly, postpartum women who underwent a cesarean section had 2.74 times higher chances of developing puerperal sepsis compared to those who had a spontaneous vaginal delivery (AOR = 2.74; 95% CI: 1.19–6.31).

Mothers who were in labor for ≥ 24 hours were 3.15 times more likely to develop puerperal sepsis compared with those < 12 hours duration of labor (AOR = 3.15; 95% CI: 1.09–9.43). Concerning the Duration of premature rupture of the membrane, mothers with PROM duration ≥ 24 hours were 3.31 times more likely to develop puerperal sepsis than mothers with PROM duration < 24 hours (AOR = 3.31; 95% CI: 1.89–5.83).

Postpartum hemorrhage was also another variable associated with puerperal sepsis, which indicated mothers who had postpartum hemorrhage were 2.57 times more likely to develop puerperal sepsis than those who had no postpartum hemorrhage (AOR = 2.57; 95% CI: 1.39–4.74).

When we see mothers’ medical co-morbidity, the odds of developing puerperal sepsis among postpartum women with anemia were 2.46 times higher as compared to those postpartum women who had no anemia (AOR = 2.46; 95% CI: 1.39–4.32).

Table 6 Bivariable & multivariable logistic regression result for the determinants of puerperal sepsis among postpartum women at Gedeo Zone public hospitals, Southern Ethiopia, 2023

This study aimed to identify the determinants of puerperal sepsis among postpartum women at a public hospital in the Gedeo Zone. According to this study, No ANC follow-up, cesarean delivery, PPH, duration of PROM, anemia, and Duration of labor ≥ 24 hours were identified as the main determinants for puerperal sepsis.

In this study, puerperal sepsis was strongly associated with ANC follow-up; Mothers who had no ANC follow-up were 4.19 times more likely to be exposed to puerperal sepsis. This is in line with a study done in a case-control study in Uganda (7) and a cross-sectional study done in Kenya (31) This may occur due to the identification and management of maternal conditions that increase the risk of puerperal sepsis, such as anemia, during ANC follow-up. However, if the mother did not receive ANC follow-up, as in the case mentioned in this study, mothers would be at risk of developing puerperal sepsis. This implies that the majority of pregnant women in low-resource settings are likely to miss out on important antepartum care schedules due to difficulties in accessing health facilities and cultural norms.

The result of this study also found that the mode of delivery had a significant association with the occurrence of puerperal sepsis. The odds of developing puerperal sepsis were 2.74 times higher among mothers delivered by cesarean than those by SVD. This finding was supported by a study conducted in the Oromia region of Ethiopia (32), Kenya (30), and Uganda (33). This can be because, in cesarean delivery, there is a prolonged hospital stay, which can increase the risk of hospital-acquired infection, poor aseptic techniques in operation rooms, and poor hygiene practices of the women after the procedure. However, this finding contradicts a study conducted in the Gondar referral hospital in which women who gave birth by C/S were 2% less likely to develop puerperal sepsis than those who gave birth through SVD (21). The variation in aseptic techniques employed in the study settings could account for this dissimilarity, while differences in methodology (such as study area, sample size, and study design) may also play a role in explaining this discrepancy.

The duration of the rupture of the membrane was also one of the other associated factors identified in this study. Mothers whose amniotic fluid membrane ruptured for more than 24 hours were 3.31 times more likely to develop puerperal sepsis. This finding is in line with a similar study in the Oromia region of Ethiopia (32) and another study in Ethiopia (22); this can be because prolonged PROM may facilitate the entrance of bacteria toward the pelvis and indirectly facilitate the development of puerperal sepsis. However, a study conducted in the USA stated that premature rupture of membranes was less likely to occur in those who eventually developed sepsis (34). The difference may be this study is facility-based, whereas the USA study is population-based. The variations might be related to health access, socio-cultural differences, population under study, and awareness.

The duration of labor was significantly associated with puerperal sepsis. Mothers who were in labor for more than 24 hours were 3.15 times more likely to develop puerperal sepsis than mothers who were in labor for less than 12 hours. This finding is similar to the study conducted in the Oromia region of Ethiopia (32), Bahirdar Ethiopia (20), the study done in Kenya (30), and Nigeria (35). This may be because prolonged labor leads women to frequent vaginal examinations, perianal tears, or episiotomies and exposes them to an ascending infection. This implies that bacterial infection can be introduced by frequent vaginal examinations, prolonged rupture of membranes, obstructed labor, and tissue damage due to prolonged labor.

The odds of experiencing puerperal sepsis were 2.57 times more likely among mothers who had postpartum hemorrhage during delivery than those who had no PPH. The findings of this study were consistent with the studies conducted in China and India (36, 37) and Tanzania (8). This might be due to placental abnormalities that could result in abnormal adherence of the placenta to the uterine endometrium, which is difficult to separate immediately after delivery of the fetus and makes the uterus lax, causing it to bleed a lot as well. This can result in uterine atony, which is the risk factor for postpartum hemorrhage (38). However, a study conducted in California, United States of America, indicated that postpartum hemorrhage was not associated with puerperal sepsis (39). The reason for these disagreements might be due to differences in the quality of health care service availability and accessibility that could help detect and manage postpartum hemorrhage during labor.

Anemia is also the other significant risk factor identified in this study. Mothers who had anemia were 2.46 times more likely to have puerperal sepsis. The findings of this study were consistent with the studies conducted in Scotland, which revealed that anemia was significantly associated with puerperal sepsis (40), China (37), and Tanzania (8). This may be because anemia exposes the development of different types of infections. The implication is that improper use of Iron-Folate and nutrition diversification during ANC follow-up caused anemia. However, those who had adequate use of Iron-Folate supplements and nutrition diversification during ANC follow-up should eliminate puerperal sepsis caused by anemia.

6.1. Strengths and Limitations of the Study

6.1.1. Strength of the Study

The strength of this study was that both controls and cases were selected from the same hospitals to reduce selection bias and use patient interviews and medical record data to access all variables.

In this study, new variables like obstructed labor, multiple pregnancies, preeclampsia, and post-term birth were added, and their significance was tested.

6.1.2. Limitation of Study

The limitation of the study was recall bias, linked to difficulty remembering events that happened in the past.

7.1. Conclusion

In this study, absence of antenatal care follow-up, undergoing a cesarean delivery, duration of PROM ≥ 24 hours, experiencing postpartum hemorrhage, duration of labor ≥ 24 hours, and having anemia were the determinant factors that increased the occurrence of puerperal sepsis among postpartum women.

7.2. Recommendations

Based on the findings of the study, the following recommendations are forwarded:

To SNNP regional health bureau and Gedeo zone health department

They should strengthen the promotion of appropriate and adequate ANC follow-up for all pregnant women.

They should inform mothers to come quickly to nearby health institutions whenever there is a sign of premature Rupture of the membrane and to strengthen its early identification and management.

They should work with community leaders and health extension workers to encourage women to labor as they should visit health facilities earlier to reduce post-partum hemorrhage.

To health professionals

They should apply proper aseptic techniques during cesarean section procedures.

They should closely identify and follow pregnant women who have premature rupture of membranes.

They should use labor management protocol properly to minimize the risk of prolonged labor.

They should focus on early initiation of appropriate management of post-partum hemorrhage for pregnant mothers.

They should focus on health information related to nutrition diversification and a balanced diet to reduce causes of anemia.

ANC: Antenatal Care, AOR: Adjusted Odds Ratio, CI: Confident Interval, C/S: Cesarean Section, COR: Crudes Odds Ratio, CSA: Central Statistical Agency, EDHS: Ethiopian Demographic and Health Survey, EMOH: Ethiopian Ministry of Health, GDM: Gestational Diabetic Mellitus, GZHD: Gedeo Zone Health Department, HIV: Human Immune-deficiency Virus, HSTP: Health Sector Transformation Plan, HTN: Hypertension, PPH: Postpartum Hemorrhage, SDG: Sustainable Development Goal, SNNPR: South Nations and Nationalities People Region, SPSS: Statistical Package for Social Science, SVD: Spontaneous Vaginal Delivery, UN: United Nation, WHO: World Health Organization

Consent for publication

Not applicable

Data and materials availability

We described all the relevant information in the manuscript but the refined dataset can be obtained from the corresponding author upon reasonable request.

Competing interests

All Authors declared that no conflicts of interest exist.

Funding

There was no funding obtained from any organization for this study.

Contributions of authors

ME: Conceptualization, methodology, software, validation, formal analysis, investigation, resources, data curation, writing - original manuscript draft, writing - review & editing, visualization, supervision, project administration.

BT: Took part in methodology, software, validation, formal analysis, investigation, writing - review & editing, visualization.

BL: Took part in methodology, software, formal analysis, investigation, writing - review & editing, and visualization.

ES: Methodology, software, validation, formal analysis, investigation, writing - review & editing, visualization.

All authors reviewed and approved the final manuscript prior to submission.

Acknowledgments

We would like to acknowledge Madda Walabu University Shashemene Campus, College of Health Science Department of Public Health, the administrative body of Hospitals from which the data was collected. The data collectors are also going to share gratitude for their contribution to data collection.

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No competing interests reported.

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Determinants of Puerperal Sepsis Among Postpartum Women at Public Hospital in Gedeo Zone, Southern Ethiopia, 2023: Unmatched Case-Control Study

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Abstract

Figures

1. INTRODUCTION

4. METHODS AND MATERIALS

5. RESULTS

5.1 Socio-demographic Characteristics

5.2. Obstetric Characteristics

5.3. Medical or Co-morbidities of the Mothers

5.4. Health facility-related factors

5.5. Determinants of puerperal sepsis among postpartum women

6. DISCUSSION

6.1. Strengths and Limitations of the Study

6.1.1. Strength of the Study

6.1.2. Limitation of Study

7. CONCLUSIONS AND RECOMMENDATIONS

7.1. Conclusion

7.2. Recommendations

Abbreviations

Declarations

References

Additional Declarations

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