Improving the prevention of maternal infection in global settings


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Dunlop, Catherine Louise ORCID: (2022). Improving the prevention of maternal infection in global settings. University of Birmingham. Ph.D.

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Introduction: The prevention of maternal infection and sepsis are essential to reduce maternal mortality and morbidity worldwide. Internationally, childbirth in healthcare facilities is actively encouraged to reduce maternal mortality; however, it can increase the risk of healthcare associated infections if infection prevention and control standards are not met. By adhering to World Health Organization (WHO) guidelines for health facilities, incidence of maternal infection can be reduced. The relevant WHO guidelines include those on: ‘water, sanitation and hygiene’; ‘hand hygiene’; and ‘recommendations for the prevention and treatment of maternal peripartum infection’. This PhD research investigated the feasibility of implementing these in maternity care, focussing on low resource settings.

Methods: Three separate studies were undertaken as part of this PhD research. (1) The UK hospital inpatient cases (n = 455) of maternal infection and sepsis during the GLOSS 1-week inception cohort study were reviewed. The aetiology, causative organisms and risk factors for severe infection were explored using descriptive statistical analysis. (2) An explanatory sequential mixed methods feasibility study entitled ‘Preventing Maternal Sepsis in Low Resource Settings’ was designed and conducted in three low resource maternity settings in Malawi. Aligned with Proctor’s implementation framework, this study investigated the feasibility of introducing the WHO guidelines using ward infrastructure surveys at 4 time points, observed hand hygiene opportunities (n=7472), patient record reviews (n=858), qualitative semi-structured interviews (n=33) and six member validation events with healthcare professionals. (3) The WHO ‘hand hygiene reminders for the work place’ were examined using a convergent mixed methods approach, investigating their acceptability in maternity settings using a survey (n=342) qualitative semi-structured interviews (n=12) and a focus group. Data collection and analysis aligned with Sekhon’s acceptability framework.

Results: Study 1: the incidence of maternal infection in inpatients in the UK was 32 cases per 1000 live births; lower than the global incidence. Most cases were endometritis or chorioamnionitis where the source was identified, in keeping with the global findings. Study 2: all sites lacked reliable access to running water. The biggest improvement to hand hygiene adherence was seen with the introduction of alcohol-based handrub; to 81%, from 8% at baseline. A significant improvement in antibiotic prophylaxis (75% at baseline to 94% after intervention (P<0.001)) and vaginal cleansing at caesarean section (0% at baseline to 58% after intervention (P<0.001)) was seen. However, long courses of antibiotic prophylaxis continued to be given against WHO guidance. Two themes (a) study context and (b) characteristics of the intervention were interpreted from the qualitative data to understand these findings and draw recommendations for randomised controlled study (RCT) scale up. Study 3: WHO hand hygiene reminders for the workplace were found to have high acceptability for use in maternity settings but did require some adaptions. Participants from high income settings reported overfamiliarity with the reminders, whereas following the guidance was an issue in low and middle income countries due to resource availability.

Conclusion: This PhD research demonstrated that it is feasible to improve the prevention of maternal infection in low resource settings. Adapting guidance and implementation strategies to the local context improved acceptability and uptake. The results are being used in an RCT assessing clinical outcomes. Additionally, the research findings have influenced development of new WHO posters and training materials, aiming to reduce global maternal mortality and morbidity from infection.

Type of Work: Thesis (Doctorates > Ph.D.)
Award Type: Doctorates > Ph.D.
Licence: All rights reserved
College/Faculty: Colleges (2008 onwards) > College of Medical & Dental Sciences
School or Department: Institute of Metabolism and Systems Research
Funders: Other
Other Funders: University of Birmingham, Ammalife
Subjects: R Medicine > RA Public aspects of medicine > RA0421 Public health. Hygiene. Preventive Medicine
R Medicine > RG Gynecology and obstetrics


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