Bacterial infections during labour and the puerperium are among the leading causes of maternal mortality worldwide, accounting for about one tenth of the global burden of maternal deaths (1, 2). While the number of deaths arising from these infections has decreased considerably in high-income settings, the situation has not improved in resource-limited settings. Most of the estimated 75,000 maternal deaths occurring worldwide yearly as a result of infections are recorded in low-income countries (3). Although the reported incidence in high-income countries is relatively low (between 0.1 and 0.6 per 1000 births), it is nonetheless an important direct cause of maternal mortality (3, 4).
Apart from deaths and acute morbidities associated with infections during or following childbirth, long-term disabilities such as chronic pelvic pain, fallopian tube blockage and secondary infertility can also occur. Maternal infections around childbirth also have a considerable impact on newborn mortality, and an estimated 1 million newborn deaths are associated with such infections annually (5, 6). In addition, infection-related morbidities and prolonged hospitalization can interfere with mother–infant bonding in the first days after birth.
Several factors have been associated with increased risk of maternal infections, including pre-existing maternal conditions (e.g. malnutrition, diabetes, obesity, severe anaemia, bacterial vaginosis, and group B streptococcus infections) and spontaneous or provider-initiated conditions during labour and childbirth (e.g. prolonged rupture of membranes, multiple vaginal examinations, manual removal of the placenta, operative vaginal birth and caesarean section) (3, 7). Caesarean section is notably the most important risk factor for infection in the immediate postpartum period, with a five- to 20-fold increased risk compared to vaginal birth. As such, the strategies to reduce maternal and newborn infections and their short- and long-term complications have been largely directed at avoiding common risk factors and promoting good infection control practices both within and outside the hospital environment.
Globally, the most common intervention for reducing morbidity and mortality related to maternal infection is the use of antibiotics for prophylaxis and treatment. Antibiotics are widely used (and misused) for obstetric conditions and procedures that are thought to carry substantial risks of infection to the mother. In many low-income countries, the use of broad-spectrum antibiotics without confirmation of the infective bacterial agent is common. Treatment of infection according to antibiotic sensitivity in this setting is constrained by poor diagnostic facilities and the need to promptly administer antibiotics to prevent severe complications. Apart from poor outcomes associated with such practice, there is increasing concern that inappropriate use and misuse of antibiotics among women giving birth could compromise public health through the emergence of resistant bacteria strains.
According to the 2014 global report on surveillance of antimicrobial resistance, resistance to common bacteria has reached alarming levels in many parts of the world (8). The WHO global strategy for containment of antimicrobial resistance underscores the importance of appropriate use of antimicrobials at different levels of the health system to reduce the impact of antimicrobial resistance, while ensuring access to the best treatment available (9). Therefore, appropriate guidance for health care professionals and policy-makers on the need for antibiotics – and the type of antibiotic regimens – for the prevention and treatment of maternal infections would align with the WHO strategy and, ultimately, improve maternal and newborn outcomes.
Definitions and terms
Various definitions and terms have been proposed for childbirth-related infections, but none are used universally. Maternal sepsis, genital tract sepsis, puerperal fever, puerperal sepsis and puerperal infection are common terms used synonymously in the literature without clarity in their definitions. A WHO technical working group defined puerperal sepsis as infection of the genital tract occurring at any time between the onset of rupture of membranes or labour and the 42nd day postpartum in which two or more of the following are present: pelvic pain, fever, abnormal vaginal discharge, abnormal smell/foul odour discharge or delay in uterine involution (10). While this definition captures well the characteristics of infections related to giving birth, the use of the term “puerperal” suggests that the onset of infection is only limited to the puerperium. Moreover, epidemiological data on childbirth-related infections have been complicated by the inclusion of other extragenital infections such as infections of the breast or urinary tract and localized or incidental infections that are unrelated to childbirth.
For clarity, the current guideline adopted the use of the term “maternal peripartum infection” to account for both intrapartum (intra-amniotic infection occurring before birth) and postpartum (or puerperal) bacterial infections related to childbirth. In this context, maternal peripartum infection is defined as bacterial infection of the genital tract or its surrounding tissues occurring at any time between the onset of rupture of membranes or labour and the 42nd day postpartum in which two or more of the following are present: pelvic pain, fever, abnormal vaginal discharge, abnormal smell/foul odour discharge or delay in uterine involution. This definition builds on an existing definition but with additional considerations for infections related to childbirth procedures or conditions (e.g. caesarean section, episiotomy and perineal tears).
Rationale and objectives
In many parts of the world, peripartum infections continue to cause avoidable deaths, not only because of inadequate access to care during childbirth but also because of poor quality of care in health facilities. Compared to other childbirth complications, the case fatality rates for childbirth-related sepsis remains very high, with rates between 4% and 50% reported in sub-Saharan Africa and South East Asia (11). The coverage of evidence-based interventions for preventing and treating maternal infectious morbidities is generally suboptimal and varies largely within and across countries. As an example, the WHO MultiCountry Survey showed that institutional coverage of antibiotic prophylaxis for caesarean birth differs considerably across and within countries, and was more related to use of clinical guidelines and audits than to the institution's size or location or the country's developmental index (12). These findings suggest considerable gaps in the quality of care and the need for development and implementation of evidence-based guidance for prevention and treatment of maternal infection at the global level. However, the few available guidelines on maternal infections are limited in scope or specific to particular context and cannot serve the interests of populations that could benefit the most.
The goal of the present guideline is to consolidate guidance for effective interventions that are needed to reduce the global burden of maternal infection and its complications around the time of childbirth. This forms part of WHO's efforts to improve the quality of care for leading causes of maternal death, especially those clustered around the time of childbirth, in the post-MDG era. The guideline is evidence-informed and covers topics related to interventions selected and prioritized by an international, multidisciplinary group of health care professionals, consumer representatives and other stakeholders. Specifically, it presents evidence-based recommendations for preventing and treating genital tract infections during labour, childbirth or puerperium, with the aim of improving outcomes for mothers and newborns. These recommendations are expected to form the basis for the development of global standards and indicators that could be adapted by WHO Member States for monitoring and improving the quality of care for maternal infections. The recommendations are intended to inform the development of relevant clinical protocols and health policies and not to provide a comprehensive practical guide for prevention and management of maternal peripartum infections.
Target audience
The target audience for this guideline includes health professionals responsible for developing national and local health protocols and policies, as well as managers of maternal and child health programmes and public health policy-makers in all settings. For policy-makers, the guideline will provide justification and support for the formulation of relevant policies and guide subsequent allocation of resources, especially in settings where a significant proportion of maternal and newborn deaths are due to complications of peripartum infections. The guideline will also be useful to those directly providing care to pregnant women, such as obstetricians, midwives, nurses and general practitioners. In settings where an inadequate health workforce has necessitated task-shifting of health worker roles, the guideline may also help mid-level providers to choose appropriate interventions to prevent or treat maternal peripartum infection before referral to higher levels of care.
Scope of the guideline
The population affected by this guideline includes pregnant women or women who have recently given birth suspected of being at risk of, or diagnosed with, bacterial infection of the genital tract or its surrounding tissues during or following vaginal or caesarean birth in a primary, secondary or tertiary care setting. The guideline will also impact on their fetus or newborn. Women with infections arising from viral, fungal, other infectious agents or bacterial infections in other areas remote from the genital tract are outside the scope of this guideline. Likewise, the guideline does not cover critical interventions for managing severe sepsis (i.e. acute organ dysfunction secondary to infection) and septicaemic shock (i.e. hypotension due to severe sepsis not reversed with fluid resuscitation).
