Recognising the burden of maternal infection worldwide
Authors: Anna C Seale
Journal: The Lancet Global Health (2020)

Maternal mortality is unacceptably high worldwide, with an estimated 300 000 women dying in 2017, of which around 200 000 deaths were in sub-Saharan Africa.1WHOMaternal Mortality.https://www.who.int/news-room/fact-sheets/detail/maternal-mortalityDate: 2019Date accessed: March 24, 2020Google Scholar Maternal infection, leading to sepsis, is a leading contributor to these deaths. Yet data for the incidence and cause of maternal infection are scarce.2Woodd SL Montoya A Barreix M et al.Incidence of maternal peripartum infection: a systematic review and meta-analysis.PLoS Med. 2019; 16e1002984Crossref PubMed Scopus (40) Google Scholar In The Lancet Global Health, Mercedes Bonet and colleagues3The WHO Global Maternal Sepsis Study (GLOSS) Research GroupFrequency and management of maternal infection in health facilities in 52 countries (GLOSS): a 1-week inception cohort study.Lancet Glob Health. 2020; 8: e661-e671Summary Full Text Full Text PDF PubMed Scopus (49) Google Scholar report findings from a study of maternal infection in 52 countries. They report the frequency of maternal clinical infections in health facilities, and relate them to severe outcomes in 2850 pregnant or recently pregnant women worldwide.3The WHO Global Maternal Sepsis Study (GLOSS) Research GroupFrequency and management of maternal infection in health facilities in 52 countries (GLOSS): a 1-week inception cohort study.Lancet Glob Health. 2020; 8: e661-e671Summary Full Text Full Text PDF PubMed Scopus (49) Google Scholar They found that 70·4 (95% CI 67·7–73·1) hospitalised women per 1000 livebirths were managed with maternal infection and 10·9 (9·8–12·0) women per 1000 livebirths had an infection-related severe maternal outcome. The study is an important step forward in showing how common and how serious maternal infections are.3The WHO Global Maternal Sepsis Study (GLOSS) Research GroupFrequency and management of maternal infection in health facilities in 52 countries (GLOSS): a 1-week inception cohort study.Lancet Glob Health. 2020; 8: e661-e671Summary Full Text Full Text PDF PubMed Scopus (49) Google Scholar The study investigated the difference in frequency of suspected or confirmed maternal infection in women delivering in health facilities in low-income and middle-income countries and high-income countries. The highest risk was observed in upper-middle-income countries (106·4 [95% CI 98·1–114·7] per 1000 livebirths), and the lowest was observed in high-income countries (38·6 [34·1–43·1] per 1000 livebirths), reflecting the differential burden of infectious diseases between these contexts. However, the difference in incidence of maternal infection between the least and most well-resourced settings is likely to be greater than that reported by Bonet and colleagues.3The WHO Global Maternal Sepsis Study (GLOSS) Research GroupFrequency and management of maternal infection in health facilities in 52 countries (GLOSS): a 1-week inception cohort study.Lancet Glob Health. 2020; 8: e661-e671Summary Full Text Full Text PDF PubMed Scopus (49) Google Scholar The least well-resourced settings almost always have the highest burden of infection, but capability is also most limited. Infrequent assessment by frontline workers with limited or no access to specialist support leads to systematic underreporting of the frequency of infections. Data are also poor for causes, as there is frequently no access to quality microbiological investigation. This study defined those managed with maternal infection as women in whom there was clinical suspicion or diagnosis of infection, a request for culture of any bodily fluid, or women who were receiving antimicrobial treatment. That these criteria were used illustrates a fundamental and important issue, which is that as yet there are no standardised criteria for maternal possible serious bacterial infection or maternal sepsis, applicable worldwide.4Bonet M Nogueira Pileggi V Rijken MJ et al.Towards a consensus definition of maternal sepsis: results of a systematic review and expert consultation.Reprod Health. 2017; 14: 67Crossref PubMed Scopus (64) Google Scholar Standard clinical criteria that are systematically applied are important, particularly in low-resource settings, to support identification and treatment of infections. They are also essential for comparisons between health facilities and studies, in terms of overall or specific incidence of particular infectious (or non-infectious) causes. In infants, simple algorithms for possible serious bacterial infection have been used to guide systematic assessment and treatment by frontline health-care workers. They have also enabled estimates of the number of cases needing treatment,5Seale AC Blencowe H Manu AA et al.Estimates of possible severe bacterial infection in neonates in sub-Saharan Africa, south Asia, and Latin America for 2012: a systematic review and meta-analysis.Lancet Infect Dis. 2014; 14: 731-741Summary Full Text Full Text PDF PubMed Scopus (183) Google Scholar studies of causes,6Saha SK Schrag SJ El Arifeen S et al.Causes and incidence of community-acquired serious infections among young children in south Asia (ANISA): an observational cohort study.Lancet. 2018; 392: 145-159Summary Full Text Full Text PDF PubMed Scopus (93) Google Scholar and facilitated pragmatic approaches to clinical trials.7Tshefu A Lokangaka A Ngaima S et al.Simplified antibiotic regimens compared with injectable procaine benzylpenicillin plus gentamicin for treatment of neonates and young infants with clinical signs of possible serious bacterial infection when referral is not possible: a randomised, open-label, equivalence trial.Lancet. 2015; 385: 1767-1776Summary Full Text Full Text PDF PubMed Scopus (98) Google Scholar Overall, the evidence base for interventions for maternal infection is limited in quantity and quality,8Bonet M Ota E Chibueze CE Oladapo OT Routine antibiotic prophylaxis after normal vaginal birth for reducing maternal infectious morbidity.Cochrane Database Syst Rev. 2017; 11CD012137PubMed Google Scholar even when compared with other very underserved groups in low-resource settings, such as neonates. As well as the need for randomised controlled trials to test specific strategies, working across the continuum of reproductive health can be used to increase opportunities. Maternal vaccines, such as that for group B streptococcus, are expected to be trialled primarily against fetal and infant outcomes. Trials such as these, or subsequent maternal vaccine probe studies, will provide an important opportunity to also assess benefit to maternal outcomes, which should not be missed.9Seale AC Baker CJ Berkley JA et al.Vaccines for maternal immunization against Group B Streptococcus disease: WHO perspectives on case ascertainment and case definitions.Vaccine. 2019; 37: 4877-4885Crossref PubMed Scopus (17) Google Scholar Bonet and colleagues make a substantial contribution to the field of maternal infection.3The WHO Global Maternal Sepsis Study (GLOSS) Research GroupFrequency and management of maternal infection in health facilities in 52 countries (GLOSS): a 1-week inception cohort study.Lancet Glob Health. 2020; 8: e661-e671Summary Full Text Full Text PDF PubMed Scopus (49) Google Scholar There remains, however, much to be done, particularly for the most disadvantaged populations. We need systematic and standardised approaches, and to maximise opportunities for collaboration across research, policy, and practice in reproductive health. Through this, we will be able to deliver improvements in the least-resourced settings for mothers, and the babies with whom they are inextricably linked. ACS is funded by The Wellcome Trust (205184) and the UK Public Health Rapid Support Team. The UK Public Health Rapid Support Team is funded by UK Aid from the Department of Health and Social Care and is jointly run by Public Health England and the London School of Hygiene & Tropical Medicine. The University of Oxford and King's College London are academic partners. The views expressed in this publication are those of the authors and not necessarily those of the National Health Service, the National Institute for Health Research, or the Department of Health and Social Care. I declare no competing interests. Frequency and management of maternal infection in health facilities in 52 countries (GLOSS): a 1-week inception cohort studyThe 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. Full-Text PDF Open Access