Knowledge and Practices of Health Workers on Prevention of Puerperal Sepsis among Mothers at Fort Portal Regional Referral Hospital
Puerperal sepsis encompasses infections after birth usually in the first 42 days following the postpartum period and is the major cause of maternal morbidity and rendered the major cause of death worldwide. Globally, puerperal sepsis is estimated to account for 15% of the 500,000 maternal deaths annually. It is the third most common cause of maternal deaths worldwide. The purpose of the study was to assess the Knowledge and Practices of health workers on the prevention of puerperal sepsis among mothers at Fort Portal Regional Referral Hospital, Fort Portal City. The study was a cross-sectional descriptive study design that used quantitative methods. A consecutive sampling method was used to select respondents. The sample size was 96 but 81 respondents were interviewed using self-administered questionnaires, where data was coded, entered using SPPS 20.1 and presented in tables, graphs and pie charts. The results showed that health workers had inadequate knowledge of puerperal sepsis where 30(45.5%) correctly described puerperal sepsis. 31(38.3%) and 29(35.8%) reported repeated vaginal exams and caesarean section as risk factors for puerperal sepsis, respectively. Practices of health workers to prevent puerperal sepsis are hand washing 45(55.5%), wearing gloves 81(100%), screening for risk factors 76(93.6%) and use of prophylactic antibiotics. In conclusion, health workers have inadequate knowledge of puerperal sepsis prevention and good practices on puerperal sepsis prevention. And the researcher recommends that all health workers in the maternity ward should undergo special training on puerperal sepsis prevention methods and more research to evaluate the techniques of the practices applied and their association with the prevention of puerperal sepsis be conducted.
Keywords: Puerperal sepsis, Infections after birth, Postpartum period, health workers, Caesarean section.
Puerperal infections date back to at least the 5th century BCE in the writings of Hippocrates . These infections were a very common cause of death around the time of childbirth starting in at least the 18th century until the 1930s when antibiotics were introduced. In 1847, in Austria, Ignaz Semmelweiss through the use of hand washing with chlorine decreased death from the disease from nearly 20% to 2% . In the 19th century, Igaz Semmelweis showed that puerperal sepsis was contagious and that it could be prevented with adequate hand hygiene. An obstetrician called Alexander Gordon was the first to prove the contagious nature of puerperal sepsis and he also advocated the need for good hygiene for its prevention in a thesis published in 1795 , . Puerperal sepsis is a genital tract infection occurring at any time within the rupture of extra placental membranes or labour and the 42nd day postpartum, characterized by symptoms like pelvic pain, fever (oral temperature of 38.5°C or higher on any occasion), abnormal vaginal discharge (the presence of pus and abnormal smell/foul odour), and delay in the involution of the uterus . The predisposing factors to puerperal sepsis include anaemia in pregnancy, prolonged labour, frequent vaginal examination, premature rupture of membranes, and use of unsterilized or unwashed instruments during delivery . A variety of bacterial pathogens has been implicated in causing puerperal sepsis including a wide range of anaerobes like peptostreptococcus, clostridia, pseudomonas and bactericides fragilis and facultative aerobes such as E. coli, enterococci, klebsiella spp, beta-hemolytic Streptococci and staphylococci . Group A streptococcus (GAS) is the most feared pathogen and up to 30% of the population are asymptomatic carriers of GAS . Puerperal sepsis is one of the five leading causes of maternal mortality worldwide and accounts for 15% of all maternal deaths annually . Postpartum sepsis accounts for most maternal deaths between three and seven days postpartum, the rate of an incidence is very high and consequently the mother and newborn virtually higher infection risk . In developed countries such as the USA, the rate of puerperal sepsis has declined significantly. For example, in the USA, puerperal sepsis in only 5.5% of vaginal deliveries and 7.4% of caesarean section deliveries . Low-resource countries account for 99% (286000) of global maternal mortalities with sub-Saharan Africa responsible for the bulk of the maternal deaths and accounting for 62% followed by southern Asia at 24% . A study conducted in Nandi County, Kenya revealed that there was a lack of knowledge on the aetiology of infection and healthcare care facilities were short of the adequate prerequisites to perform puerperal sepsis awareness both in the clinic and community . In Uganda, puerperal sepsis is the leading cause of maternal death accounting for 30.9% of the direct causes of Maternal Mortality at Mbarara RR Hospital. The current Maternal Mortality Ratio (MMR) in Uganda is 438 per 100,000 live births coming from 550 per 100,000 in 1990. Mortality rates are thought to be higher in areas that lack proper sanitation .
Knowledge of Health workers on prevention of puerperal sepsis
This showed that the majority 40(81.6%) of the respondents had knowledge of puerperal sepsis. This agrees with the study done on preventive measures of puerperal sepsis by  which found that most of respondents 30(60%) had knowledge on puerperal sepsis and its preventive measures. The study found that the majority 28(57.2%) of the health workers described puerperal sepsis incorrectly with only 21(42.8%) describing puerperal sepsis as bacterial infection of the female reproductive tract post-delivery within 6 weeks. This finding agrees with the findings of a study done by  in the United Kingdom which attributed the occurrence of sepsis to limited awareness of sepsis among health personnel and poor identification with delayed intervention. This study also revealed that the majority of 39(79.6%) of the health workers knew the signs and symptoms of puerperal sepsis with 37(75.5%) of the respondents identifying correctly the signs and symptoms of puerperal sepsis. This finding contradicts with a study by the World Sepsis Declaration, 2014 which concluded that there is too little knowledge in identifying sepsis signs and symptoms among physicians and nursing staff . This study revealed inadequate knowledge on components of hand hygiene, one of the key measures of prevention of puerperal sepsis with 25(51.0%) of the respondents mentioning washing hands, 11(22.4%) mentioning the use of disinfectants and 15(30.6%) mentioning wearing gloves. This study contradicts a study conducted among medical students which revealed poor knowledge of hand hygiene with more than 40% of the study participants being unaware of the importance of hand washing . The study also revealed that the majority 38(77.6%) of the health workers accepted that hand hygiene is important in the prevention of puerperal sepsis, with majority 34(69.4%) of the respondents suggested that hand hygiene prevents puerperal sepsis by reducing the spread of infection and/or eradication of microorganisms. This study contradicts a study by  which found out more than 40% of the study participants were unaware of the importance of hand washing . In this study, it was revealed that respondents had knowledge of the risk factors of puerperal sepsis as health workers were able to mention some the risk factors like early rupture of membranes/prolonged labour 30(61.2%), retained products of conception and manual removal of placenta 10(20.4%), chronic illnesses like HIV/AIDS and DM 25(51.0%), Urinary Tract Infection 24(49.0%), caesarian section 18(36.7%), repeated vaginal examinations 18(36.7%) and anaemia/malnutrition 22(44.9%). This study contradicts the studies that indicated that female health workers have low knowledge about an emergency to stabilize the patient prior to referral and identify and manage complications arising during pregnancy and prevention and treatment of pregnancy-related problems hence there was an urgent need to redesign the basic training of health workers working in the management of gynaecological problems . This study revealed inadequate knowledge on important measures necessary in the prevention of puerperal sepsis in antepartum, intrapartum and postpartum as 20(40.8%) respondents suggested regular antenatal visits, 07(14.2%) suggested hand hygiene,21(42.9%) suggested aseptic technique and 18(36.7%) suggested use of prophylactic antibiotics were necessary. This, therefore, puts many mothers at a high risk of developing puerperal sepsis, thus raising its prevalence. The result of this research contradicts the study in Ghana on the knowledge and attitude of health workers and patients on sepsis which indicated that most health workers had knowledge on how to prevent sepsis postpartum with a 100% of the health workers mentioning thorough hand washing with soap as one of the methods . This study is in line with a report by the International Journal of Science and Research on the use of antibiotics and the presence of skilled healthcare staff globally, aseptic precautions advance in investigation tools, improvement in MCH services, and trained birth attendants at delivery have played a major role in reducing the incidence of puerperal sepsis . This research also showed that the majority 34(69.4%) of the respondents did not know GAS guidelines. This agrees with a study conducted on Provider Knowledge, Attitude and Practices regarding Obstetric and Postsurgical Gynecologic Infections Due to GAS which showed a lack of awareness of GAS guidelines among one of their targeted audiences, which was due to a lack of knowledge of the existence of these guidelines, most likely because the guidelines are published in a journal not read by these respondents .
Practices of Health Workers on Prevention of puerperal sepsis
The research found that the majority 27(55.1%) of the respondent washed their hands each time they conducted a vaginal examination. This study’s finding contradicts  finding that compliance among health workers in regard to regular and frequent hand washings is typically below 40%. The same research finding also disagrees with the statement by  that there is a vast amount of evidence that shows there is low compliance to hand washing by health workers, with hands being washed either infrequently or inadequately as only 12(14.8%) of the respondents washed their hands very rarely. This research showed that the majority 29(59.2%) of the respondents did not conduct a vaginal examination every after four hours as it is recommended, with a significant number of 15(30.6%) health workers conducting vaginal examination every after one hour. This finding was practiced against the study recommendations by  that limiting digital vaginal examination at the interval of four hours is an important consideration in the prevention of puerperal sepsis. The study also found out that 28(57.1%) of the health workers isolate mothers with sepsis, 04(8.2%) avoided pubic hair shaving prior to vaginal birth and 20(40.8%) of the respondents practiced proper waste disposal and daily damp dusting, which indicated inadequate practice to prevent puerperal sepsis. This is contradicting the founding of  that general improvement of hospital sanitation like appropriate waste disposal, isolation of patients with sepsis, and avoiding routine perineal/pubic shaving prior to vaginal birth are key health workers’ practices for the prevention of puerperal sepsis. However, this study did not consider the relationship between waste disposal, isolation of patients with sepsis and avoiding routine perineal/pubic shaving prior to vaginal birth and the occurrence of puerperal sepsis. The table above shows that all respondents 49(100%) wear gloves while conducting child birth, 07(14.3%) wear gowns, 21(42.9%) put on protective aprons, 08(16.3%) wear gum boots and 09(18.4%) wear face masks. This agrees with a Kenyan study by  on the use of protective gear, where findings revealed that most health workers conducted deliveries using gloves, aprons, headgear and gumboots. The research also showed that the majority 38(77.6%) of the respondents use surgical gloves while performing vaginal examination as a means of preventing puerperal sepsis. This agrees with  that the use of clean equipment such as the use of surgical gloves during the vaginal examination was a recommended practice in the prevention of puerperal infections. The study revealed that the majority 31(63.3%) of the respondents use the autoclave to sterilize delivery sets as one way practiced so as to prevent puerperal sepsis. This agrees with the statement that the use of pre-packed sterilized delivery kits is a recommended practice in the prevention of puerperal infections . This study also showed that the majority 27(55.1%) of health workers give prophylactic broad-spectrum antibiotics to mothers at risk of sepsis. This is in line with the statement that the most common intervention for reducing morbidity and mortality related to maternal infection globally is the use of antibiotics for prophylaxis and treatment . The research revealed that the majority 45(91.8%) of the respondents give prophylactic antibiotics to all mothers on the ward irrespective of whether there was a need or not. This to some extent agrees with the  report that many low-income countries use broad-spectrum antibiotics without confirmation of the infective bacterial agent. The study also revealed that health workers administer prophylactic antibiotics to mothers with risks of puerperal sepsis such as postpartum haemorrhage 10(20.4%), urinary tract infection 43(87.6%), caesarian section 28(57.1%), early rupture of membranes 22(44.9%), malnourished mothers 13(26.5%), and comorbidities like HIV/AIDS, STI, diabetes mellitus 14(28.6%) This agrees with the findings of  that antibiotics are widely used (and misused) for obstetric conditions and procedures that are thought to carry substantial risks of infection to the mother. The research also indicated that above shows that most health workers screened mothers for conditions that predispose them to puerperal sepsis such as identified HIV/AIDS 45(91.8%), STDs 45(91.8%), urinary tract infections 31(63.3%), malnutrition 41(83.7%) and diabetes mellitus 14(28.6%) this agrees with a statement that conditions such as diabetes mellitus, urinary tract infections, anaemia, malnutrition and HIV/AIDS are a risk factor to puerperal sepsis and therefore diagnosis and treatment of such conditions during antenatal visits is a key practice in the prevention of puerperal sepsis -. The research above showed that majority 38 (77.6%) of those whom the training on sepsis benefited the ability to detect early signs and symptoms of sepsis and improved care for mothers with sepsis. This agrees with the statement that the need for education and training of healthcare staff helps health workers in the early identification of subtle signs of developing sepsis , -.
- Health workers have inadequate knowledge and generally good practices on prevention of puerperal sepsis which could be due to limited continuous medical education.
- Puerperal sepsis cases can be greatly reduced through timely screening, appropriate prophylactic antibiotics to reduce pathogenic bacteria and appropriate treatment as well as prevention of prenatal risk factors to the disease like antepartum haemorrhage, urinary tract infection, and early rupture of membranes which cause ascending infection, malnutrition, anaemia and comorbidities like HIV/AIDS, and diabetes mellitus. These compromise adaptive and innate immunity to pathogens.
- Low social class mothers are at risk of developing postpartum sepsis due to low hygienic settings like limited Mama Kites and habits of mothers using local remedies during pregnancy and postpartum.
- Health workers’ use of clean and safe deliveries through practices like the use of protective gear, thorough hand washing with soap and avoidance of frequent vaginal examination during labour and provision of prophylactic antibiotics can reduce the incidence of puerperal sepsis.
- Health education to mothers and health workers training on puerperal sepsis is an important pillar in the prevention and treatment of postpartum sepsis.
- All health workers should undergo special training on puerperal sepsis pointing out its prevention methods, identification of signs and symptoms and management of the disease.
- Pregnant mothers should also have health education sessions when they come for antenatal care so that risks like poor hygiene which is common among the low social class that predisposes mothers to postpartum sepsis can be overcome.
- Application of GAS guidelines among health workers should be emphasized in order to control and prevent morbidity and mortality of mothers resulting from postpartum infections.
- Follow-up teams should be created at health centres to ensure appropriate care for all pregnant mothers with risks for puerperal sepsis is adequately provided.
- Refresher courses on clean and safe deliveries should be provided to all midwives, nurses and general practitioners.
- Conduct more research to evaluate the techniques of the practices applied and their association with the prevention of puerperal sepsis.
- Walvekar and Vandana (2005). Manual of perinatal infections New Delhi: Jaypee Bros.p.153. ISBN9788180614729.
- Anderson, B. L. (2014). Puerperal group A streptococcal infection: beyond Semmelweis. Obstetrics and gynaecology, 123(4): 874-82.
- Gould I. M. (2010). Alexander Gordon, puerperal sepsis, and modern theories of infection control–Semmelweis in perspective. The Lancet. Infectious diseases, 10(4), 275–278. https://doi.org/10.1016/S1473-3099(09)70304-4
- Ezimah, A. C., Obeagu, E. I., Ahmed, H., Ezimah, U. A., & Ezimah, C. O. (2016). The prognostic significance of neutrophil polymorph and band counts in under-five children with sepsis in Umth. Int J Adv Res Biol Sci, 3, 68-74.
- World Health Organization. (2008).World health statistics 2008. World Health Organization. https://apps.who.int/iris/handle/10665/43890
- Raymond, K., Belinda, B. and Mecky, M. (2019). Laboratory confirmed puerperal sepsis in a national referral hospital in Tanzania: etiological agents and their susceptibility to commonly prescribed antibiotics. BMC Infectious Diseases 19: 690 (2019).
- Tamoli, S. S., Musa, J., Karshima, J. A., & Ifenne, D. I. (2017). Effects of puerperal sepsis on early neonatal mortality. PLoS One. 2017; 12(2): e0170856. Doi: 10. 1371/journal pone0170856. Medline.
- Wynne, A. & Bigna, S. B. (2015). Puerperal sepsis in the 21st century: progress, new challenges and the situation worldwide. Postgraduate Medical Journal vol 91, 2015.
- Bartlett, L. A., LeFevre, A. E., Soofi, A. S., Mitra, D. K., Quaiyum, M. A., Shakoor, S., Islam, M. S., Connor, N. E., Winch, P. J., Reller, M. E., Shah, R. E., Arifeen, S., Baqui, A. H., Bhutta, Z. A., Zaidi, A., Saha, S. & Ahmed, S. A. (2016) Postpartum Sepsis Study Group. The development and evaluation of a community-based clinical diagnosis tool and treatment regimen for postpartum sepsis in Bangladesh and Pakistan. Reprod Health.
- World Health Organization. (2016).World health statistics 2016: monitoring health for the SDGs, sustainable development goals. World Health Organization. https://apps.who.int/iris/handle/10665/206498
- Ngonzi, J. (2016). Effectiveness of structured teaching program on prevention of puerperal infection among primi postnatal mothers at Mbarara Regional Hospital. [PhD Thesis]. Mbarara, Uganda: Mbarar University of Science and Technology.
- Martin, V. C. & Jackim, N. (2017). Associated factors with Puerperal Sepsis among Reproductive Age Women in Nandi County, Kenya, Journal of Midwifery Reproductive Health.
- Aruna, R. (2016). Puerperal sepsis. National Health Portal, India
- FIGO (2018). Sepsis and its Impact on maternal mortality.
- Sustainable Development Solutions Network (2014). Indicators for Sustainable Development Goals. United Nations.http://doi.org/10.3390/su5072840.
- Yahaya, S. J. & Bukar, H. (2018). Knowledge of symptoms and signs of puerperal sepsis in a community in north-eastern Nigeria: A cross-sectional study. Journal of Obstetrics and Gynaecology, 33(2), 152-154, 2018.
- United Nations (2015). Sustainable Development Goals.
- Ugwu, C. N., & Eze, V. H. U. (2023). Qualitative Research. IDOSR of Computer and Applied Science, 8(1), 20–35.
- Ugwu Chinyere Nneoma, Eze Val Hyginus Udoka, Ugwu Jovita Nnenna, Ogenyi Fabian Chukwudi and Ugwu Okechukwu Paul-Chima (2023). Ethical Publication Issues in the Collection and Analysis of Research Data. NEWPORT INTERNATIONAL JOURNAL OF SCIENTIFIC AND EXPERIMENTAL SCIENCES (NIJSES) 3(2): 132-140.
- Ambrose, B. M., Iwueke, A. V., Miriam, N., Shimwela, D. M., Deshpande, R. and Neel, G. R. (2016). Factors contributing to puerperal sepsis at Kampala International University Teaching Hospital- Ishaka Bushenyi-Uganda.
- McClelland, H. & Moxon, A. (2014). Early Identification and Treatment of Sepsis. Nursing Times, 16. Available on http//web.b.ebscohost.com.
- World Sepsis Declaration Report, 2014.
- Hannah, , Muiru, E. (2018). Knowledge, attitude and barriers to hands hygiene practice: a study of Kampala International University undergraduate medical students. Int J Community Med Public Health, 5:3782-7.
- Fatusi, A. O., Makinde, O. N., Adeyemi, A. B., Orji, E. O., & Onwudiegwu, U. B. (2017). Evaluation of health workers’ training in the use of the partogram. International Journal of Gynecology Obstetrics, 20: 30-30.
- Irene, O., Daniel, N. A. & Tagoe, G. (2014). Knowledge and attitude of health workers and patients on sepsis. Asian Pacific Journal of Tropical Disease.v.4 (2).
- Rajwant, K. & Reena, J. (2014). Enhancement of Knowledge Regarding Puerperal Sepsis among Female Health Workers. International Journal of Science and Research.
- Chris, A., Lauri, A. H., Lauri, E. R. & Jay, S. (2015). Provider KAP regarding Obstetric and Postsurgical Gynecologic Infections Due to Group A. Streptococcus and Other Infectious Agents. Advanced Journal List- Infectious Disease in Obstetrics and Gynecology.
- Howard, M. (2015). Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health.
- Rick, F. (2019). Hand hygiene effectiveness in hospitals infection control. https://inivos.com/blog/hhand-hygiene-effectiveness-in-hospital-infection-control/.
- Athula, F., Silva, D. Y., Gange, V. P., Uduwerella, S. B., Rathnayake, C, Gayan, D. S. & Ruwan, W. P. (2019). Management of Puerperal Sepsis. General National Guidelines SLCOG.
- WHO (2015). Trends in Maternal Mortality: 1990 To 2013. Estimates by WHO, UNICEF, UNFBA, The World Bank and The United Nations Population Division. Geneva: (WHO; 2008/2014).
- Smail, F. M. & Gyten, G. M. (2010). Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section. Cochrane Database Syst Rev.
- Ged, B. & Screaton, J. (2016). The current state of sepsis education and training for healthcare Staff across England.
- Mulegi, T. (2022). An Overview of Performance of Health Workers in Uganda. IDOSR Journal of Humanities and Social Sciences. 7(1), 113-124.
- Harunah, S. (2023). Assessments of Puerperal Sepsis in Women at Kampala International University Teaching Hospital Western Campus, Uganda. IDOSR Journal of Biochemistry, Biotechnology and Allied Fields. 8(1), 42-52.
- Emmanuel Ifeanyi Obeagu, Benjamin Kigabo Ndakize, Okechukwu Paul-Chima Obeagu, Getrude Uzoma, Ugwu, Kazibwe Sophia. (2023). Neonatal Sepsis: Haematological Perspectives. IDOSR Journal of Scientific Research. 8(2), 161-166.
- Felix, A. (2023). Assessment of factors associated with burden of Puerperal Sepsis in maternity women at Ishaka Adventist Hospital Bushenyi District. INOSR Experimental Sciences. 11(2), 32-41.
- Mercy, M. M. (2023). Knowledge and Practices on Infection Control among Health Workers in Jinja Regional Referral Hospital. NEWPORT International Journal of Scientific and Experimental Sciences. 3(2), 141-148.
CITE AS: Kambale Allan (2023). Knowledge and Practices of Health Workers on Prevention of Puerperal Sepsis among Mothers at Fort Portal Regional Referral Hospital. IDOSR JOURNAL OF APPLIED SCIENCES 8(3) 25-44. https://doi.org/10.59298/IDOSR/2023/10.2.1412