GLOSS is an initiative from the World Health Organization (WHO) and the Human Reproduction Programme (HRP) and involves researchers and organisations from around the world, including NPEU Professor of Maternal and Child Population Health Marian Knight. The new results, published in The Lancet Global Health, are the first to provide data on frequency of maternal infections and sepsis across the pregnancy and post-pregnancy period.
According to the new data, around 11 women per 1000 live births had an infection which resulted in or contributed to what is known as a severe maternal outcome – either they died or nearly died – during their hospitalisation. The researchers say that urgent improvement is needed to manage this life-threatening risk faced by all pregnant and recently pregnant women. Overall, around 70 pregnant or recently-pregnant women per 1000 live births were found to have a maternal infection needing hospital management.
In low- and middle-income countries up to 15 women per 1000 births suffered a severe maternal outcome.
Infections were the underlying cause of most of the deaths recorded during the study, primarily post-abortion infection and indirect infections. Infections were also present in about a third of deaths attributed to other causes, such as postpartum haemorrhage. This suggests that the contribution of infection to global maternal mortality and morbidity may be larger than current reports of maternal sepsis mortality suggest.
Maternal sepsis is a life-threatening condition that arises when the body’s response to infection causes injury to its own tissues and organs during pregnancy, child-birth, post-abortion or the postpartum period.
The latest global estimates place sepsis due to obstetric infections as the third most common cause of maternal mortality, but only include infections as a direct result of pregnancy, such as post-caesarean wound infections. The new study includes post-abortion infections and indirect infections such as respiratory and meningitis, which are aggravated by pregnancy but not directly caused by it.
The study gathered data from healthcare facilities on women who were admitted with suspected or confirmed infection during pregnancy or post-pregnancy over a one-week period in 2017. More than 2800 women participated in the study in 52 countries.
Some of the most common maternal infections found in the study, such as urinary tract infections, post-caesarean and post-abortion infections, are largely preventable and treatable. For a third of the women, a complete set of vital signs was not collected and treatment was frequently delayed.
GLOSS results suggest that current levels of monitoring and clinical care across health facilities are not enough to prevent, identify and treat levels of maternal infection effectively.
The higher burden in low- and middle-income countries may reflect the impact of broader health determinants in different country contexts. Challenges of overcrowding, limited access to water and sanitation and constraints to safe births by skilled birth attendants can reduce the ability of healthcare providers to manage the frequency and outcome of maternal infections.
Professor Marian Knight coordinated the European study. It is the first WHO global study of severe maternal morbidity to include information from several western European countries. The UK data were collected through the UK Obstetric Surveillance System (UKOSS), and European data through the International Network of Obstetric Survey Systems (INOSS), a network of countries who have systems similar to UKOSS.
Sepsis has been recognised for some time as an important cause of maternal death and severe illness in the UK, and this study clearly shows that this is also the case worldwide. Severe infection relating to pregnancy is often under-recognised, and this study highlights the need for additional awareness amongst women, families and healthcare workers across the globe.