Sepsis after childbirth (post-partum) is emerging as a significant cause of maternal mortality in Kerala, raising questions about the quality of obstetric and postnatal care given to women and the efficacy of infection-control practices in hospitals.
The Kerala Federation of Obstetrics and Gynaecology (KFOG), which has been conducting a confidential review of maternal deaths in the State since 2004, has reported that if in 2006 sepsis accounted for seven per cent of all maternal deaths and was its fifth leading cause, in 2009, it was the third leading cause, responsible for 8 per cent of all maternal deaths.
“Post-partum haemorrhage (19.38 per cent) and hypertensive disorders (12 per cent) continue to be the most common causes of maternal mortality in Kerala. However, the fact that sepsis is gaining an upper hand should be a cause of worry for us because it is a clear indication of poor practice of aseptic techniques in the labour room, poor general hygiene in hospitals, and lack of an aggressive treatment approach to infections,” V. Rajasekharan Nair, senior obstetrician and Dean, Faculty of Medicine, Kerala University of Health and Allied Sciences, says.
Sepsis has become a growing issue the world over of late, and is linked to the dipping levels of general hygiene in hospitals, the increasing number of surgeries being performed in operation theatres, shortage of manpower or other inadequacies in hospitals, and most importantly, the growing problem of antibiotic resistance fuelled by indiscriminate use of antibiotics.
Maternal sepsis (referred to infection in a woman during pregnancy, labour, or till the 42nd day post-partum) accounted for the death of 57 women in the post-partum period out of a total of 676 maternal deaths in the State between 2006 and 2009. Of the 32 sepsis deaths reviewed by the federation, 23 followed Caesarean-section deliveries.
The KFOG’s maternal death review showed that 20 of the 32 sepsis deaths occurred within a week of the delivery, indicating that these were fulminant infections (sudden, severe, or lethal infections).
The KFOG report says that when it is a well-known fact that pregnancy and the immediate state of the woman after childbirth are very immuno-compromised states, an aggressive diagnosis and management of sepsis can prevent unnecessary loss of lives.
Prolonged induction of labour, traumatic delivery, anaemia or malnutrition, and C-sections are some of the major pre-disposing factors to maternal sepsis. Of the 676 maternal deaths reported in the State between 2006 and 2009, 180 maternal deaths were associated with C-sections, and 24 followed elective C-sections.
The KFOG report says it does not mean that in all cases, C-sections led to sepsis because there were other complications also. However, with sepsis gaining ground, the increasing rate of C-sections in the State, especially in the first pregnancy, is a cause for concern, P.K. Jameela, Director of Health Services, says.
Aggressive hospital infection-control policies, a common antibiotic policy, aseptic precautions in the labour rooms, and general improvement in hygiene and cleanliness can go a long way in controlling sepsis.
Many senior obstetricians say that there are major hospitals in the State that do not have 24-hour water supply or even running water in operation theatres or labour rooms.
Shortage of cleaning staff is a major issue affecting the hygiene levels in most government hospitals.
“As 99.6 per cent of all deliveries take place in hospitals in Kerala, the State should formulate a comprehensive sepsis management strategy, focussing on more efficient hospital-based infection-control programmes,” Dr. Nair says.