,, ,oUK_,oo Longman Group Ltd 1991
Midwifery
Puerperal sepsis: its contribution to maternal mortality Barbara E Kwast
P u e r p e r a l sepsis is the second m o s t c o m m o n cause o f m a t e r n a l mortality in the d e v e l o p i n g world. I n this p a p e r the e x t e n t o f the p r o b l e m is described a n d factors a f f e c t i n g p u e r p e r a l sepsis are identified. M e t h o d s o f r e d u c i n g the incidence o f p u e r p e r a l sepsis are suggested. T h i s p a p e r is based o n o n e originally given at the I C M / W H O / U N I C E F p r e - c o n g r e s s w o r k s h o p in Kobe, J a p a n , October, 1990.
INTRODUCTION Every year half a million women die in pregnancy and childbirth (see Kwast, 1991a). The major obstetric causes are haemorrhage, sepsis, pregnancy induced hypertension (eclampsia), obstructed labour and illicit induced abortion. The part haemorrhage plays in maternal mortality has already been reviewed (Kwast, 1991b). In this paper the extent of the problem of sepsis in relation to maternal mortality is presented. Factors affecting maternal mortality are identified and the case for competent midwives in the prevention, early detection and prompt treatment of sepsis is made.
THE MAGNITUDE More women die during the puerperium (from the end of labour until six weeks' postpartum) than during pregnancy and labour combined (Koenig et al, 1988; Kwast, 1989). Community Barbara E Kwaat M Comm H, PhD, SCM, MTD, Scientist, Maternal & Child Health, World Health Organization, 1211, Geneva, 27, Switzerland. Requests for offprints to BEK
102
based studies in Bangladesh reveal that 17% of deaths were during pregnancy, 15% during labour, 18% post abortion and 50% postpartum (Koenig et al, 1988). In Ethiopia, 87% of deaths took place after delivery (Kwast, 1989). Abnormalities of pregnancy and complications of difficult labour have their aftermath during the puerperium. The present discussion is confined to postpartum sepsis as deaths from post-abortal sepsis are not included here. A review of the literature shows that generally postpartum sepsis is the second most important cause of maternal death, accounting for about 23% of all maternal deaths in developing countries (WHO, 1988, unpublished review). This means that 115 000 women die from puerperal sepsis annually and if nothing is done between now and the year 2000, another one million women will perish from this cause. This, however, is not the whole story as the majority of deaths do not occur in the presence of a single complication. Usually two or more obstetric or medical complications contribute to a maternal death and thus there may be an under estimate of one particular cause of death. Harrison and Rossiter (1985) demonstrate this clearly in the Zaria study where of all the complications in the puerperium, genital sepsis and anaemia were
MIDWIFERY 103 the most frequent, both in survivors and fatalities. O f the 219 deaths from major puerperal complications, just over 80% (90% in the case of vesico-vaginal fistula and palsy) had genital sepsis, anaemia or both. Eighty percent of all deaths from sepsis occur in the Asia region and a further 17% in the African region (WHO, 1988, unpublished review). Maternal mortality rates due to puerperal sepsis are 178 and 113 sepsis deaths per 100000 live births in Middle South Asia and West Africa respectively (WHO, 1988, unpublished review). Studies in Cote d'Ivoire, T h e Gambia, Nigeria, Pakistan, Egypt, Tanzania and Malawi reveal between 27% and 30% of deaths are due to puerperal sepsis (Janjua, 1979; Justesen, 1985; Bohoussou, 1986; Adetoro, 1987; Keller, 1987; E1 Kady et al, 1989). The following eight studies in Asia exhibit a uniformity in that within the rank order of maternal deaths, sepsis rates second after haemorrhage: Bangladesh China India Indonesia Korea
-
7% (Koenig et al, 1988); 16% (Zhang & Ding, 1986); 12% (Bhatia, 1986); 27% (Chiet al, 1986); 13% (Republic of Korea Ministry of Health & Welfare, 1984); Nepal - 17% (Malla, 1986); Sri Lanka - 7% (SriLanka Ministry of Health, 1987); The Phillipines - 16% (Sahagun, 1987).
However, it is worth noting that even in countries which have achieved relatively low rates of maternal mortality, e.g. China (27/ 100000), Korea (26/100000), and Sri Lanka (80/100 000) sepsis is still the second most important cause of death (Republi c of Korea Ministry of Health & Welfare, 1984; Zhang & Ding, 1986; Sri Lanka Ministry of Health, 1987).
FACTORS AFFECTING PUERPERAL SEPSIS Obstetric and medical factors Genital sepsis is almost always the result of
intervention during labour and delivery (Stewart, 1967). Serious infections are rare in normal labour provided there has been no undue interference or too frequent vaginal examinations. T h e dangerous infections follow prolonged and obstructed labour and many of those develop into septicaemia (Stewart, 1967). T h e woman in neglected obstructed l a b o u r - - exhausted, dehydrated and frequently already anaemic during pregnancy - - is particularly vulnerable to infection. T h e anaemia is made worse by the sepsis and unless corrected, recovery of the woman is severely hampered (Barnes, 1979). Once septicaemia occurs, thrombophlebitis, pulmonary embolism and disseminated intravascular coagulation may complicate the infection (Stewart, 1967). Severe postpartum sepsis which has progressed to septicaemia may be further complicated by septic shock with a very high maternal mortality (Stewart, 1967). T h e diagnosis o f puerperal genital sepsis depends mainly on early observation and correct interpretation of physical signs. It is important to remember that clostridium infections may be difficult to detect early enough as they may not cause pyrexia, and the woman's temperature may even be subnormal (Stewart, 1967). Clostridium infections occur where contamination with earth or cow dung is a possibility (Howard, 1987). It is therefore important that pregnant women are immunised when it is envisaged that they will deliver at home in disadvantaged circumstances to protect themselves from tetanus and their baby from contracting neonatal tetanus (Galaska et al, 1989).
Health service factors Due to shortage o f beds it is necessary in many countries to send women home within a few hours after delivery. Where there is no domiciliary midwifery service, potential complications must be anticipated. T h e r e are now several studies which report the histories of women who were discharged early and came back with septicaemia between the seventh and twelfth postnatal day and subsequently died (Keller, 1987; Kwast, 1989).
104
MIDWIFERY
T h e majority o f deaths f r o m genital sepsis and anaemia seem to occur between the first and second week of the p u e r p e r i u m (Harrison & Rossiter, 1985; Justesen, 1985; Walker et al, 1986; Kwast, 1989). T h e severity o f the underlying complication plays an important role. While many women who died have come late after complications have occurred at home, medical and midwifery/nursing staff factors are contributary in hospital, and a m o n g these are: inadequate surveillance of t e m p e r a t u r e in women in prolonged labour and after delivery; - - lack of a sepsis and antisepsis during surgical procedures; --inadequate bacteriological investigations in women with puerperal sepsis; - - shortage of blood for transfusion; --inadequate treatment with appropriate antibiotics or further operative intervention; - - non-availability of a p p r o p r i a t e drugs (Janjua, 1979; Justesen, 1985; Walker et al, 1986; Keller, 1987).
--
Socio-economic status and cultural factors Anaemia, malnutrition and p o o r hygiene are important determinants for sepsis in the puerperium. All three factors are linked to low socio-economic status which in turn will be a deterrent to use the formal health service because o f inaccessibility (Harrison & Rossiter, 1985; Bhatia, 1986; Kwast, 1989). In societies where early marriage is c o m m o n and the delivery of the first child has to take place at h o m e for traditional reasons, prolonged and obstructed labour is a serious cause o f complications and maternal mortality (Harrison & Rossiter, 1985). T h e study in Zaria showed clearly that maternal and fetal survival was poorest a m o n g primigravidae y o u n g e r than 15 years (Harrison & Rossiter, 1985). T h e young teenage girls constituted 3% of the survey population and 30% of the 174 maternal deaths, while the highly parous women m a d e u p 10% of the survey population and 20% o f the maternal
deaths. O f 1443 w o m e n with vesico-vaginal fistula, over 60% occurred following h o m e delivery and one in three o f the women was aged less than 16 years. T h e relationship between prolonged labour and vesico-vaginal fistula and puerperal sepsis has been explained u n d e r the magnitude o f puerperal sepsis. Antenatal care, unless it has some influence over the selection of the place of delivery, cannot prevent puerperal sepsis per se. However, the majority o f studies show that women who received antenatal care have a significantly lower risk of dying. Antenatal care is often provided at low or no cost, while the same does not apply to delivery care (Kwast, 1988). Unless the social service system can be mobilised, where this exists, to make provision for the most needy to deliver in a health institution, even the most efficient high risk selection antenatally will be of no avail. This has been demonstrated in a study in Papua New Guinea, where 71% o f women with a high risk factor still gave birth at h o m e (Lennox, 1984). It was also shown that 70% of complications occurred in women with a high risk pregnancy while 30% of complicated deliveries took place in women who had no high risk factors (Lennox, 1984).
PROBLEMS RELATED TO MIDWIFERY EDUCATION I f maternal mortality due to sepsis is to be reduced midwives have to be educated in its prevention, early detection and p r o m p t treatment. This education should include the following: (1) A recognition o f the traditional customs and belief systems in their area, in particular to the nature o f infection; (2) Recognition of the need to ascertain the coverage of antenatal and delivery care in their area; (3) Midwives need to be taught how to help communities to learn about risk factors in pregnancy and labour which predispose to puerperal sepsis;
MIDWIFERY 105 (4) Use of the p a r t o g r a p h to p r e v e n t prol o n g e d labour; (5) T h e n e e d for midwives to m a i n t a i n strict asepsis a n d antisepsis; (6) T h e n e e d to give health e d u c a t i o n to w o m e n o n early discharge following delivery a b o u t signs o f i n f e c t i o n a n d w h e n to r e p o r t back to the m i d w i f e or health centre; (7) T h e n e e d to supervise traditional birth a t t e n d a n t s a n d / o r give feedback o n referrals by T B A s to i m p r o v e practice; (8) T h e n e e d to p r o v i d e family p l a n n i n g services for the w o m e n at h i g h risk of p u e r p e r a l infection. I n o r d e r that w o m e n can b e t t e r withstand the effects o f sepsis midwives m u s t be e q u i p p e d to diagnose a n d treat a n a e m i a in p r e g n a n c y a n d other i n t e r c u r r e n t infections. Midwives m u s t also be t a u g h t a n d a u t h o r i s e d to prescribe antibiotic t h e r a p y in cases of p r o l o n g e d r u p t u r e of m e m b r a n e s , p r o l o n g e d l a b o u r a n d at the first sign o f infection in the p u e r p e r i u m .
CONCLUSION P u e r p e r a l sepsis is the second m a j o r cause of m a t e r n a l mortality in the d e v e l o p i n g world. It is almost always d u e to i n t e r v e n t i o n i n l a b o u r a n d this is i n t e r - r e l a t e d with p r o l o n g e d a n d obstructed labour, a n a e m i a , m a l n u t r i t i o n a n d poor hygiene. As with o t h e r causes o f m a t e r n a l mortality p u e r p e r a l sepsis is m o r e c o m m o n in w o m e n f r o m the lower socio-economic groups. I f mortality a n d m o r b i d i t y are to be r e d u c e d it is necessary that professional midwives, T B A s a n d the c o m m u n i t y as a whole are e d u c a t e d in the causes o f p u e r p e r a l sepsis. Midwives will t h e n be able to take steps to help p r e v e n t it, detect it early w h e n it does occur a n d treat it p r o m p t l y .
References Adetoro O O 1987 Maternal mortality - a twelve year survey at the University of Ilorin Teaching Hospital (UITH) Nigeria. InternationalJournal of Gynecology & Obstetrics 25:93-98
Barns T E C 1979 Obstetrics in the third world with particular reference to field research into delivery of maternal care to the community. In Stallworthy J, Bourne G. (eds) Recent Advances in Obstetrics and Gynaecology. Churchill Livingstone, Edinburgh Bhatia J C 1986 A study of maternal mortality in Anantapur district, Andhra Pradesh, India. Indian Institute of Management, Bangalore, India Bohoussou K M, Boni S, Anongba Set al 1986 La mortalite maternelle au cours de la parturition et le post-partum immediat. Etude hospitaliers Afrique Medicale 25(239): 125-130 Chi I C, Agoestina T, Harbin J et al 1981 Maternal mortality at twelve teaching hospitals in Indonesia: an epidemiologic analysis. InternationalJournal of Gynecology & Obstetrics 19(4): 259-266 El Kady A A, Saleh S, Gadalla Set al 1989 Obstetric deaths in Menoufia Governorate, Egypt. British Journal of Obstetrics & Gynaecology 96:9-14 Galaska A, Gasse F, Henderson R H 1989 Neonatal tetanus and The Global Expanded Programme on Immunization. In Kessel E, Awan A K (eds) Maternal and child care in developing countries. Ott Publishers, 3607 Thun 7, Switzerland Harrison K A & Rossiter C E 1985 In Harrison K A (ed) Childbearing, Health and Social Priorities. British Journal of Obstetrics & Gynaecology 92, Suppl. 5: 100-113 Howard D 1987 Aspects of maternal morbidity: the experience of less developed countries. Advances in International Maternal & Child Health 7:1 Janjua S 1979 National University in major city hospitals in Pakistan. Journal of the Pakistan Medical Association 29(2): 31-35 Justesen A 1985 An analysis of maternal mortality in Muhimbili Medical Centre, Dares Salaam July 1983 to June 1984. Journal of Obstetrics & Gynaecology of East & Central Africa 4:5-8 Keller M E 1987 Maternal mortality at Kamuzu Central Hospital for 1985. Medical Quarterly, Journal of the Medical Association of Malawi 4(1): 13-16 Koenig M A, Fauveau V, Chowdhury A Iet al 1988 Maternal mortality in Matlab, Bangladesh. Studies in Family Planning 19(4): 197-214 Korea, Republic of 1984 Major policies and programmes in health and social welfare services. Ministry of Health and Welfare, Soeul, Korea Kwast B E 1988 Maternity services and TBAs in Addis Ababa: biosocial factors related to birth place and outcome of pregnancy. Health Policy and Planning 3(2): 109-118 Kwast B E 1989 Unsafe motherhood - a monumental challenge. Kwast, van Geerstrat 13, Leiderdorp, The Netherlands. ISBN 90-9002173-6 Kwast B E 1991a Maternal mortality: the magnitude and causes. Midwifery 7(1): 4-7 Kwast B E 1991b Puerperal haemorrhage: its contribution to maternal mortality. Midwifery 7(2): 64-70 Lennox C E 1984 Assessment of obstetric high risk factors in a developing country. Tropical Doctor, July: 125-128 Malla D S 1986 Study on causes of maternal death in Nepal. Unpublished report. Government of Nepal, Kathmandu
106
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Ministry of Health Sri Lanka 1987 Maternal mortality statistics. Ministry of Health, Colombo, Sri Lanka Sahagun G 1987 The Philippines Hospital maternal deaths: causes and implications. Paper presented at the National Conference on Safe Motherhood, Manila, 3-4 September 1987. Department of Health, Manila, Philippines Stewart D B (1967) Complications of the puerperium In Lawson J B, Stewart D B (eds) Obstetrics and Gynaecology in the tropics. Edward Arnold, London
Walker G J A, McCaw A M, Ashley D E C et al 1986 Maternal mortality in Jamaica. Lancet 1(8479): 486488 Zhang L and Ding H 1986 China: Analysis of cause and rate of regional maternal death in 21 provinces, municipalities and autonomous regions. Chinese Journal of Obstetrics & Gynaecology 21(4): 195-197
Midwifery
Puerperal sepsis: its contribution to maternal mortality Barbara E Kwast
P u e r p e r a l sepsis is the second m o s t c o m m o n cause o f m a t e r n a l mortality in the d e v e l o p i n g world. I n this p a p e r the e x t e n t o f the p r o b l e m is described a n d factors a f f e c t i n g p u e r p e r a l sepsis are identified. M e t h o d s o f r e d u c i n g the incidence o f p u e r p e r a l sepsis are suggested. T h i s p a p e r is based o n o n e originally given at the I C M / W H O / U N I C E F p r e - c o n g r e s s w o r k s h o p in Kobe, J a p a n , October, 1990.
INTRODUCTION Every year half a million women die in pregnancy and childbirth (see Kwast, 1991a). The major obstetric causes are haemorrhage, sepsis, pregnancy induced hypertension (eclampsia), obstructed labour and illicit induced abortion. The part haemorrhage plays in maternal mortality has already been reviewed (Kwast, 1991b). In this paper the extent of the problem of sepsis in relation to maternal mortality is presented. Factors affecting maternal mortality are identified and the case for competent midwives in the prevention, early detection and prompt treatment of sepsis is made.
THE MAGNITUDE More women die during the puerperium (from the end of labour until six weeks' postpartum) than during pregnancy and labour combined (Koenig et al, 1988; Kwast, 1989). Community Barbara E Kwaat M Comm H, PhD, SCM, MTD, Scientist, Maternal & Child Health, World Health Organization, 1211, Geneva, 27, Switzerland. Requests for offprints to BEK
102
based studies in Bangladesh reveal that 17% of deaths were during pregnancy, 15% during labour, 18% post abortion and 50% postpartum (Koenig et al, 1988). In Ethiopia, 87% of deaths took place after delivery (Kwast, 1989). Abnormalities of pregnancy and complications of difficult labour have their aftermath during the puerperium. The present discussion is confined to postpartum sepsis as deaths from post-abortal sepsis are not included here. A review of the literature shows that generally postpartum sepsis is the second most important cause of maternal death, accounting for about 23% of all maternal deaths in developing countries (WHO, 1988, unpublished review). This means that 115 000 women die from puerperal sepsis annually and if nothing is done between now and the year 2000, another one million women will perish from this cause. This, however, is not the whole story as the majority of deaths do not occur in the presence of a single complication. Usually two or more obstetric or medical complications contribute to a maternal death and thus there may be an under estimate of one particular cause of death. Harrison and Rossiter (1985) demonstrate this clearly in the Zaria study where of all the complications in the puerperium, genital sepsis and anaemia were
MIDWIFERY 103 the most frequent, both in survivors and fatalities. O f the 219 deaths from major puerperal complications, just over 80% (90% in the case of vesico-vaginal fistula and palsy) had genital sepsis, anaemia or both. Eighty percent of all deaths from sepsis occur in the Asia region and a further 17% in the African region (WHO, 1988, unpublished review). Maternal mortality rates due to puerperal sepsis are 178 and 113 sepsis deaths per 100000 live births in Middle South Asia and West Africa respectively (WHO, 1988, unpublished review). Studies in Cote d'Ivoire, T h e Gambia, Nigeria, Pakistan, Egypt, Tanzania and Malawi reveal between 27% and 30% of deaths are due to puerperal sepsis (Janjua, 1979; Justesen, 1985; Bohoussou, 1986; Adetoro, 1987; Keller, 1987; E1 Kady et al, 1989). The following eight studies in Asia exhibit a uniformity in that within the rank order of maternal deaths, sepsis rates second after haemorrhage: Bangladesh China India Indonesia Korea
-
7% (Koenig et al, 1988); 16% (Zhang & Ding, 1986); 12% (Bhatia, 1986); 27% (Chiet al, 1986); 13% (Republic of Korea Ministry of Health & Welfare, 1984); Nepal - 17% (Malla, 1986); Sri Lanka - 7% (SriLanka Ministry of Health, 1987); The Phillipines - 16% (Sahagun, 1987).
However, it is worth noting that even in countries which have achieved relatively low rates of maternal mortality, e.g. China (27/ 100000), Korea (26/100000), and Sri Lanka (80/100 000) sepsis is still the second most important cause of death (Republi c of Korea Ministry of Health & Welfare, 1984; Zhang & Ding, 1986; Sri Lanka Ministry of Health, 1987).
FACTORS AFFECTING PUERPERAL SEPSIS Obstetric and medical factors Genital sepsis is almost always the result of
intervention during labour and delivery (Stewart, 1967). Serious infections are rare in normal labour provided there has been no undue interference or too frequent vaginal examinations. T h e dangerous infections follow prolonged and obstructed labour and many of those develop into septicaemia (Stewart, 1967). T h e woman in neglected obstructed l a b o u r - - exhausted, dehydrated and frequently already anaemic during pregnancy - - is particularly vulnerable to infection. T h e anaemia is made worse by the sepsis and unless corrected, recovery of the woman is severely hampered (Barnes, 1979). Once septicaemia occurs, thrombophlebitis, pulmonary embolism and disseminated intravascular coagulation may complicate the infection (Stewart, 1967). Severe postpartum sepsis which has progressed to septicaemia may be further complicated by septic shock with a very high maternal mortality (Stewart, 1967). T h e diagnosis o f puerperal genital sepsis depends mainly on early observation and correct interpretation of physical signs. It is important to remember that clostridium infections may be difficult to detect early enough as they may not cause pyrexia, and the woman's temperature may even be subnormal (Stewart, 1967). Clostridium infections occur where contamination with earth or cow dung is a possibility (Howard, 1987). It is therefore important that pregnant women are immunised when it is envisaged that they will deliver at home in disadvantaged circumstances to protect themselves from tetanus and their baby from contracting neonatal tetanus (Galaska et al, 1989).
Health service factors Due to shortage o f beds it is necessary in many countries to send women home within a few hours after delivery. Where there is no domiciliary midwifery service, potential complications must be anticipated. T h e r e are now several studies which report the histories of women who were discharged early and came back with septicaemia between the seventh and twelfth postnatal day and subsequently died (Keller, 1987; Kwast, 1989).
104
MIDWIFERY
T h e majority o f deaths f r o m genital sepsis and anaemia seem to occur between the first and second week of the p u e r p e r i u m (Harrison & Rossiter, 1985; Justesen, 1985; Walker et al, 1986; Kwast, 1989). T h e severity o f the underlying complication plays an important role. While many women who died have come late after complications have occurred at home, medical and midwifery/nursing staff factors are contributary in hospital, and a m o n g these are: inadequate surveillance of t e m p e r a t u r e in women in prolonged labour and after delivery; - - lack of a sepsis and antisepsis during surgical procedures; --inadequate bacteriological investigations in women with puerperal sepsis; - - shortage of blood for transfusion; --inadequate treatment with appropriate antibiotics or further operative intervention; - - non-availability of a p p r o p r i a t e drugs (Janjua, 1979; Justesen, 1985; Walker et al, 1986; Keller, 1987).
--
Socio-economic status and cultural factors Anaemia, malnutrition and p o o r hygiene are important determinants for sepsis in the puerperium. All three factors are linked to low socio-economic status which in turn will be a deterrent to use the formal health service because o f inaccessibility (Harrison & Rossiter, 1985; Bhatia, 1986; Kwast, 1989). In societies where early marriage is c o m m o n and the delivery of the first child has to take place at h o m e for traditional reasons, prolonged and obstructed labour is a serious cause o f complications and maternal mortality (Harrison & Rossiter, 1985). T h e study in Zaria showed clearly that maternal and fetal survival was poorest a m o n g primigravidae y o u n g e r than 15 years (Harrison & Rossiter, 1985). T h e young teenage girls constituted 3% of the survey population and 30% of the 174 maternal deaths, while the highly parous women m a d e u p 10% of the survey population and 20% o f the maternal
deaths. O f 1443 w o m e n with vesico-vaginal fistula, over 60% occurred following h o m e delivery and one in three o f the women was aged less than 16 years. T h e relationship between prolonged labour and vesico-vaginal fistula and puerperal sepsis has been explained u n d e r the magnitude o f puerperal sepsis. Antenatal care, unless it has some influence over the selection of the place of delivery, cannot prevent puerperal sepsis per se. However, the majority o f studies show that women who received antenatal care have a significantly lower risk of dying. Antenatal care is often provided at low or no cost, while the same does not apply to delivery care (Kwast, 1988). Unless the social service system can be mobilised, where this exists, to make provision for the most needy to deliver in a health institution, even the most efficient high risk selection antenatally will be of no avail. This has been demonstrated in a study in Papua New Guinea, where 71% o f women with a high risk factor still gave birth at h o m e (Lennox, 1984). It was also shown that 70% of complications occurred in women with a high risk pregnancy while 30% of complicated deliveries took place in women who had no high risk factors (Lennox, 1984).
PROBLEMS RELATED TO MIDWIFERY EDUCATION I f maternal mortality due to sepsis is to be reduced midwives have to be educated in its prevention, early detection and p r o m p t treatment. This education should include the following: (1) A recognition o f the traditional customs and belief systems in their area, in particular to the nature o f infection; (2) Recognition of the need to ascertain the coverage of antenatal and delivery care in their area; (3) Midwives need to be taught how to help communities to learn about risk factors in pregnancy and labour which predispose to puerperal sepsis;
MIDWIFERY 105 (4) Use of the p a r t o g r a p h to p r e v e n t prol o n g e d labour; (5) T h e n e e d for midwives to m a i n t a i n strict asepsis a n d antisepsis; (6) T h e n e e d to give health e d u c a t i o n to w o m e n o n early discharge following delivery a b o u t signs o f i n f e c t i o n a n d w h e n to r e p o r t back to the m i d w i f e or health centre; (7) T h e n e e d to supervise traditional birth a t t e n d a n t s a n d / o r give feedback o n referrals by T B A s to i m p r o v e practice; (8) T h e n e e d to p r o v i d e family p l a n n i n g services for the w o m e n at h i g h risk of p u e r p e r a l infection. I n o r d e r that w o m e n can b e t t e r withstand the effects o f sepsis midwives m u s t be e q u i p p e d to diagnose a n d treat a n a e m i a in p r e g n a n c y a n d other i n t e r c u r r e n t infections. Midwives m u s t also be t a u g h t a n d a u t h o r i s e d to prescribe antibiotic t h e r a p y in cases of p r o l o n g e d r u p t u r e of m e m b r a n e s , p r o l o n g e d l a b o u r a n d at the first sign o f infection in the p u e r p e r i u m .
CONCLUSION P u e r p e r a l sepsis is the second m a j o r cause of m a t e r n a l mortality in the d e v e l o p i n g world. It is almost always d u e to i n t e r v e n t i o n i n l a b o u r a n d this is i n t e r - r e l a t e d with p r o l o n g e d a n d obstructed labour, a n a e m i a , m a l n u t r i t i o n a n d poor hygiene. As with o t h e r causes o f m a t e r n a l mortality p u e r p e r a l sepsis is m o r e c o m m o n in w o m e n f r o m the lower socio-economic groups. I f mortality a n d m o r b i d i t y are to be r e d u c e d it is necessary that professional midwives, T B A s a n d the c o m m u n i t y as a whole are e d u c a t e d in the causes o f p u e r p e r a l sepsis. Midwives will t h e n be able to take steps to help p r e v e n t it, detect it early w h e n it does occur a n d treat it p r o m p t l y .
References Adetoro O O 1987 Maternal mortality - a twelve year survey at the University of Ilorin Teaching Hospital (UITH) Nigeria. InternationalJournal of Gynecology & Obstetrics 25:93-98
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