Availability of facility resources and services and infection-related maternal outcomes in the WHO Global Maternal Sepsis Study: a cross-sectional study

The Lancet Global Health, Volume 9, No. 9, Year 2021

Interpretation

Background: Infections are among the leading causes of maternal mortality and morbidity. The Global Maternal Sepsis and Neonatal Initiative, launched in 2016 by WHO and partners, sought to reduce the burden of maternal infections and sepsis and was the basis upon which the Global Maternal Sepsis Study (GLOSS) was implemented in 2017. In this Article, we aimed to describe the availability of facility resources and services and to analyse their association with maternal outcomes. Methods: GLOSS was a facility-based, prospective, 1-week inception cohort study implemented in 713 health-care facilities in 52 countries and included 2850 hospitalised pregnant or recently pregnant women with suspected or confirmed infections. All women admitted for or in hospital with suspected or confirmed infections during pregnancy, childbirth, post partum, or post abortion at any of the participating facilities between Nov 28 and Dec 4 were eligible for inclusion. In this study, we included all GLOSS participating facilities that collected facility-level data (446 of 713 facilities). We used data obtained from individual forms completed for each enrolled woman and their newborn babies by trained researchers who checked the medical records and from facility forms completed by hospital administrators for each participating facility. We described facilities according to country income level, compliance with providing core clinical interventions and services according to women’s needs and reported availability, and severity of infection-related maternal outcomes. We used a logistic multilevel mixed model for assessing the association between facility characteristics and infection-related maternal outcomes. Findings: We included 446 facilities from 46 countries that enrolled 2560 women. We found a high availability of most services and resources needed for obstetric care and infection prevention. We found increased odds for severe maternal outcomes among women enrolled during the post-partum or post-abortion period from facilities located in low-income countries (adjusted odds ratio 1·84 [95% CI 1·05–3·22]) and among women enrolled during pregnancy or childbirth from non-urban facilities (adjusted odds ratio 2·44 [1·02–5·85]). Despite compliance being high overall, it was low with regards to measuring respiratory rate (85 [24%] of 355 facilities) and measuring pulse oximetry (184 [57%] of 325 facilities). Interpretation: While health-care facilities caring for pregnant and recently pregnant women with suspected or confirmed infections have access to a wide range of resources and interventions, worse maternal outcomes are seen among recently pregnant women located in low-income countries than among those in higher-income countries; this trend is similar for pregnant women. Compliance with cost-effective clinical practices and timely care of women with particular individual characteristics can potentially improve infection-related maternal outcomes. Funding: UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, Merck for Mothers, and US Agency for International Development. The protocol and initial findings from GLOSS were published elsewhere.6, 7 In short, GLOSS was a facility-based, prospective, 1-week inception cohort study implemented in 713 health-care facilities in 52 countries, including 2850 hospitalised pregnant or recently pregnant women with suspected or confirmed infections, accompanied by an awareness campaign.12 All women admitted for or in hospital with suspected or confirmed infections during pregnancy, childbirth, post partum, or post abortion at any of the participating facilities between Nov 28 and Dec 4, 2017, were eligible for inclusion in GLOSS. Written informed consent or a waiver of written consent (opt-out) was obtained depending on each country’s requirements. Ethical approval for GLOSS was obtained from the WHO’s Ethics Review Committee (protocol ID A65787), and from the ethics committees of the respective countries and facilities according to national regulations. Data were collected using three different paper-based forms: individual forms for each enrolled woman and their newborn babies that were completed by trained researchers who checked the medical records; facility forms completed by hospital administrators for each participating facility; and area forms for each participating geographical area that were completed by study country coordinators. Individual-level data regarding identification and management of the infection were collected for up to 6 weeks or until discharge, transfer outside of study area, or death of the participant, as well as for their newborn babies up to 7 days after birth. These data included information relating to pregnancy status at enrolment to the study, clinical signs and symptoms during the first 3 days upon admission to hospital, and pregnancy and maternal outcomes. Facility-level data included information on location, administration, type of health-care institution (primary [level I], secondary [level II], or tertiary [level III]),13 and availability of specific services and interventions on the day that the form was completed, including clinical practices (eg, cultures, laboratory services, checking for clinical signs), obstetric care capacity, infection prevention measures, and availability of WASH, medicines, and treatments for women and neonates. Additionally, feasibility for detection of organ dysfunction, availability of protocols, and the presence of infection prevention and control committees were recorded for each facility. Data were entered manually into a web-based data management system developed for the study. Further details on the GLOSS protocol can be found in the appendix (pp 1–2). We present our data according to STROBE guidelines (appendix pp 3–5). Of 713 facilities participating in GLOSS (maternity hospitals, referral or district hospitals, and general hospitals), we included those for which facility data were collected. We excluded facilities from countries not collecting these data (six countries, 267 facilities). We used data from the facility-level and individual-level forms for this analysis. For the definition of compliance, we calculated the percentage of women within facilities who received interventions according to individual clinical need, by quartiles (≤25%, >25 to ≤50%, >50 to <75%, and ≥75%). Because we wanted to identify the facilities in the highest or lowest quartiles, we classified facilities as having low (up to 25% of women received a given intervention), intermediate (more than 25% but less than 75% of women received said interventions), or high compliance (at least 75% received said intervention). We defined country income level as low-income (LIC), lower-middle-income (LMIC), and upper-middle-income or high-income (UMHIC) using World Bank country classifications for 2018. To ensure standardisation throughout all the facilities with regards to capacity for basic emergency obstetric and newborn care, instead of relying on the form item that asked whether the facility had this capacity, we looked at facilities' reported availability of seven basic interventions: parenteral antibiotics, anticonvulsants, uterotonics, manual removal of placenta, removal of retained products, assisted vaginal delivery, and newborn resuscitation. Similarly, for comprehensive emergency obstetric and newborn care, we assessed for two additional interventions: surgery (ie, caesarean section) and blood transfusion. We created a caesarean index to identify the number of births delivered by caesarean section as a proportion of the total number of deliveries in 2016. For this index, we used a range of 13–17% as a reference, following guidance for suggested caesarean section rates.14 We present proportions to report facility characteristics by country income level and by severity of maternal outcome, and compliance with measuring clinical signs or laboratory testing (ie, temperature, white blood cell count) as required according to suspicion or confirmation of infection. We used a logistic multilevel mixed model using facility and individual characteristics to look at the association between these characteristics and infection-related maternal outcomes. We modelled infection-related maternal outcomes in two categories: severe maternal outcomes and non-severe maternal outcomes (ie, infections with complications and less severe infections). The reference category was non-severe maternal outcomes. Infection-related severe maternal outcome includes women with WHO near-miss criteria or maternal death. Infections with complications includes women who required an invasive procedure to treat the source of infection (eg, vacuum aspiration, dilatation and curettage, wound debridement, drainage [incision, percutaneous, culdotomy], laparotomy and lavage, other surgery), admission to intensive care unit or high dependency care, or transfer to another facility. All other women were considered to have less severe infections. We adjusted for key facility-level and individual-level variables in one stage on the basis of their clinical significance. For the list of variables included in the models, see the appendix (pp 1–2). We dichotomised compliance as high (≥75%) and not high (<75%) to allow for sufficient cases in each of the groups. To account for clustering and to control for a possible correlation between observations within each geographical area in participating countries, we included the country as a random effect in the models. We used two different models, one for women who were enrolled in the study during pregnancy or childbirth and another for women enrolled post partum or post abortion, given that the pathogenesis and clinical presentation of infections tend to be different between these two groups.15, 16 A consistency analysis was done to assess missing data; the analysis found that missing data were random and not systematic, so we included all observations in all further analyses. Statistical significance is reported at p<0·05. All statistical analyses were done using R, version 4.0.0 (R Foundation for Statistical Computing, Vienna, Austria). The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.

AI Digest

Study Justification:

The Global Maternal Sepsis Study (GLOSS) was conducted to address the significant burden of maternal infections and sepsis, which are leading causes of maternal mortality and morbidity. The study aimed to assess the availability of facility resources and services and analyze their association with infection-related maternal outcomes. By understanding the factors that contribute to poor maternal outcomes, the study aimed to inform interventions and improve the quality of care provided to pregnant and recently pregnant women with infections.

Highlights:

– GLOSS was a large-scale, facility-based study conducted in 713 healthcare facilities across 52 countries.
– The study included 2,560 hospitalised pregnant or recently pregnant women with suspected or confirmed infections.
– The availability of most services and resources needed for obstetric care and infection prevention was found to be high.
– Women enrolled during the post-partum or post-abortion period from facilities located in low-income countries had increased odds of severe maternal outcomes.
– Women enrolled during pregnancy or childbirth from non-urban facilities also had increased odds of severe maternal outcomes.
– Compliance with cost-effective clinical practices, such as measuring respiratory rate and pulse oximetry, was found to be low in some facilities.
– The study highlights the need for improved compliance with clinical practices and timely care to improve infection-related maternal outcomes.

Recommendations:

Based on the study findings, the following recommendations can be made:

1. Strengthen healthcare facilities in low-income countries to improve the availability of resources and services for obstetric care and infection prevention.
2. Focus on improving compliance with cost-effective clinical practices, such as measuring respiratory rate and pulse oximetry, to ensure timely and accurate diagnosis and management of infections.
3. Enhance training and capacity-building programs for healthcare providers to improve the quality of care provided to pregnant and recently pregnant women with infections.
4. Develop and implement infection prevention and control protocols in healthcare facilities to reduce the risk of maternal infections and sepsis.
5. Increase investment in healthcare infrastructure and resources to support the delivery of high-quality obstetric care and infection prevention services.

Key Role Players:

1. Ministry of Health: Responsible for policy development, coordination, and oversight of healthcare services.
2. Healthcare Facility Administrators: Responsible for implementing and managing facility-level interventions and ensuring compliance with clinical practices.
3. Healthcare Providers: Including doctors, nurses, and midwives, responsible for providing direct care to pregnant and recently pregnant women with infections.
4. Research Institutions: Responsible for conducting further research and evaluation to inform evidence-based interventions and policies.
5. Non-Governmental Organizations (NGOs): Involved in providing support, training, and resources to healthcare facilities and providers.

Cost Items for Planning Recommendations:

1. Infrastructure Development: Budget for the construction or renovation of healthcare facilities to improve infrastructure and ensure adequate space for obstetric care and infection prevention.
2. Equipment and Supplies: Budget for the procurement of medical equipment, instruments, and supplies necessary for infection prevention, diagnosis, and treatment.
3. Training and Capacity-Building: Budget for training programs and workshops to enhance the skills and knowledge of healthcare providers in managing maternal infections.
4. Research and Evaluation: Budget for conducting further research and evaluation to monitor the impact of interventions and inform future policies and practices.
5. Awareness Campaigns: Budget for developing and implementing awareness campaigns to educate the public and healthcare providers about the importance of infection prevention and timely care for pregnant and recently pregnant women.
Please note that the above cost items are general categories and the actual cost will vary depending on the specific context and requirements of each healthcare facility and country.

Strength of Evidence

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on a large-scale, prospective study conducted in 713 healthcare facilities in 52 countries. The study collected data from 2560 women and analyzed the association between facility resources and services and infection-related maternal outcomes. The findings show a high availability of most services and resources needed for obstetric care and infection prevention. However, there are some limitations that can be addressed to improve the evidence. First, the abstract does not provide information on the specific methods used for data collection and analysis, which could be important for assessing the validity of the findings. Second, the abstract does not mention whether any statistical tests were conducted to determine the significance of the associations reported. Including this information would strengthen the evidence. Lastly, the abstract does not provide information on potential confounding factors that were controlled for in the analysis. Addressing these limitations and providing more details on the methods and analysis would further improve the strength of the evidence.

Abstract

The protocol and initial findings from GLOSS were published elsewhere.6, 7 In short, GLOSS was a facility-based, prospective, 1-week inception cohort study implemented in 713 health-care facilities in 52 countries, including 2850 hospitalised pregnant or recently pregnant women with suspected or confirmed infections, accompanied by an awareness campaign.12 All women admitted for or in hospital with suspected or confirmed infections during pregnancy, childbirth, post partum, or post abortion at any of the participating facilities between Nov 28 and Dec 4, 2017, were eligible for inclusion in GLOSS. Written informed consent or a waiver of written consent (opt-out) was obtained depending on each country’s requirements. Ethical approval for GLOSS was obtained from the WHO’s Ethics Review Committee (protocol ID A65787), and from the ethics committees of the respective countries and facilities according to national regulations. Data were collected using three different paper-based forms: individual forms for each enrolled woman and their newborn babies that were completed by trained researchers who checked the medical records; facility forms completed by hospital administrators for each participating facility; and area forms for each participating geographical area that were completed by study country coordinators. Individual-level data regarding identification and management of the infection were collected for up to 6 weeks or until discharge, transfer outside of study area, or death of the participant, as well as for their newborn babies up to 7 days after birth. These data included information relating to pregnancy status at enrolment to the study, clinical signs and symptoms during the first 3 days upon admission to hospital, and pregnancy and maternal outcomes. Facility-level data included information on location, administration, type of health-care institution (primary [level I], secondary [level II], or tertiary [level III]),13 and availability of specific services and interventions on the day that the form was completed, including clinical practices (eg, cultures, laboratory services, checking for clinical signs), obstetric care capacity, infection prevention measures, and availability of WASH, medicines, and treatments for women and neonates. Additionally, feasibility for detection of organ dysfunction, availability of protocols, and the presence of infection prevention and control committees were recorded for each facility. Data were entered manually into a web-based data management system developed for the study. Further details on the GLOSS protocol can be found in the appendix (pp 1–2). We present our data according to STROBE guidelines (appendix pp 3–5). Of 713 facilities participating in GLOSS (maternity hospitals, referral or district hospitals, and general hospitals), we included those for which facility data were collected. We excluded facilities from countries not collecting these data (six countries, 267 facilities). We used data from the facility-level and individual-level forms for this analysis. For the definition of compliance, we calculated the percentage of women within facilities who received interventions according to individual clinical need, by quartiles (≤25%, >25 to ≤50%, >50 to <75%, and ≥75%). Because we wanted to identify the facilities in the highest or lowest quartiles, we classified facilities as having low (up to 25% of women received a given intervention), intermediate (more than 25% but less than 75% of women received said interventions), or high compliance (at least 75% received said intervention). We defined country income level as low-income (LIC), lower-middle-income (LMIC), and upper-middle-income or high-income (UMHIC) using World Bank country classifications for 2018. To ensure standardisation throughout all the facilities with regards to capacity for basic emergency obstetric and newborn care, instead of relying on the form item that asked whether the facility had this capacity, we looked at facilities' reported availability of seven basic interventions: parenteral antibiotics, anticonvulsants, uterotonics, manual removal of placenta, removal of retained products, assisted vaginal delivery, and newborn resuscitation. Similarly, for comprehensive emergency obstetric and newborn care, we assessed for two additional interventions: surgery (ie, caesarean section) and blood transfusion. We created a caesarean index to identify the number of births delivered by caesarean section as a proportion of the total number of deliveries in 2016. For this index, we used a range of 13–17% as a reference, following guidance for suggested caesarean section rates.14 We present proportions to report facility characteristics by country income level and by severity of maternal outcome, and compliance with measuring clinical signs or laboratory testing (ie, temperature, white blood cell count) as required according to suspicion or confirmation of infection. We used a logistic multilevel mixed model using facility and individual characteristics to look at the association between these characteristics and infection-related maternal outcomes. We modelled infection-related maternal outcomes in two categories: severe maternal outcomes and non-severe maternal outcomes (ie, infections with complications and less severe infections). The reference category was non-severe maternal outcomes. Infection-related severe maternal outcome includes women with WHO near-miss criteria or maternal death. Infections with complications includes women who required an invasive procedure to treat the source of infection (eg, vacuum aspiration, dilatation and curettage, wound debridement, drainage [incision, percutaneous, culdotomy], laparotomy and lavage, other surgery), admission to intensive care unit or high dependency care, or transfer to another facility. All other women were considered to have less severe infections. We adjusted for key facility-level and individual-level variables in one stage on the basis of their clinical significance. For the list of variables included in the models, see the appendix (pp 1–2). We dichotomised compliance as high (≥75%) and not high (<75%) to allow for sufficient cases in each of the groups. To account for clustering and to control for a possible correlation between observations within each geographical area in participating countries, we included the country as a random effect in the models. We used two different models, one for women who were enrolled in the study during pregnancy or childbirth and another for women enrolled post partum or post abortion, given that the pathogenesis and clinical presentation of infections tend to be different between these two groups.15, 16 A consistency analysis was done to assess missing data; the analysis found that missing data were random and not systematic, so we included all observations in all further analyses. Statistical significance is reported at p<0·05. All statistical analyses were done using R, version 4.0.0 (R Foundation for Statistical Computing, Vienna, Austria). The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.

Materials

https://efashare.b-cdn.net/materials/8ae6fb5f23cd0c4e5a8e635b59c123fe7524556001998fa1f4bf889944e37502/mmc1.pdf

Innovations

Based on the provided information, here are some potential innovations that could improve access to maternal health:

1. Strengthening Health Care Facilities: Enhancing the availability of resources and services in health care facilities, particularly in low-income countries, can improve maternal outcomes. This could involve improving infrastructure, ensuring the availability of essential medical supplies and equipment, and increasing the capacity of health care providers.

2. Enhancing Compliance with Clinical Practices: Improving compliance with cost-effective clinical practices, such as measuring respiratory rate and pulse oximetry, can contribute to better infection-related maternal outcomes. This may involve training health care providers on the importance of these practices and implementing monitoring systems to ensure adherence.

3. Timely Care for Women with Individual Characteristics: Providing timely and appropriate care for women with specific individual characteristics can help improve maternal outcomes. This could include targeted interventions for women in the post-partum or post-abortion period, as well as those in non-urban areas.

4. Infection Prevention and Control: Implementing effective infection prevention and control measures in health care facilities is crucial for reducing maternal infections and sepsis. This may involve improving hygiene practices, promoting handwashing, ensuring proper sterilization of equipment, and implementing protocols for infection control.

5. Collaboration and Awareness Campaigns: Collaborating with international organizations, governments, and local communities to raise awareness about maternal health and the importance of accessing quality care can help improve access to maternal health services. This could involve conducting awareness campaigns, providing education and information, and addressing cultural and social barriers that may hinder access to care.

It’s important to note that these recommendations are based on the information provided and may need to be tailored to specific contexts and resources available in each setting.

AI Innovations Description

The study mentioned, titled “Availability of facility resources and services and infection-related maternal outcomes in the WHO Global Maternal Sepsis Study: a cross-sectional study,” aimed to assess the availability of facility resources and services and their association with maternal outcomes related to infections. The study was conducted in 713 health-care facilities across 52 countries and included 2,850 pregnant or recently pregnant women with suspected or confirmed infections.

The findings of the study revealed that most health-care facilities had a high availability of resources and interventions required for obstetric care and infection prevention. However, there were worse maternal outcomes observed among women in low-income countries and non-urban facilities. Compliance with cost-effective clinical practices, such as measuring respiratory rate and pulse oximetry, was also found to be low in some facilities.

Based on these findings, the following recommendations can be made to develop innovations and improve access to maternal health:

1. Strengthening Facility Resources: Efforts should be made to ensure that health-care facilities, especially those in low-income countries and non-urban areas, have adequate resources and infrastructure to provide quality obstetric care and infection prevention. This may include improving access to essential medical supplies, equipment, and trained healthcare professionals.

2. Enhancing Compliance with Clinical Practices: Strategies should be implemented to improve compliance with cost-effective clinical practices, such as regular monitoring of respiratory rate and pulse oximetry. This can be achieved through training programs for healthcare providers, the development of standardized protocols, and regular monitoring and feedback mechanisms.

3. Promoting Timely Care: Timely and appropriate care for women with suspected or confirmed infections is crucial in improving maternal outcomes. Efforts should be made to ensure that women receive prompt and effective treatment, including timely administration of antibiotics and other necessary interventions.

4. Addressing Disparities: Special attention should be given to addressing disparities in maternal outcomes between low-income countries and higher-income countries, as well as between urban and non-urban areas. This may involve targeted interventions, increased investment in healthcare infrastructure, and improved access to quality maternal health services in underserved areas.

5. Collaboration and Knowledge Sharing: Collaboration between countries, healthcare facilities, and international organizations is essential for sharing best practices, lessons learned, and innovative approaches to improving access to maternal health. This can help accelerate progress and ensure that successful interventions are replicated and scaled up effectively.

By implementing these recommendations, it is possible to develop innovative solutions that can improve access to maternal health and reduce the burden of maternal infections and sepsis worldwide.

AI Innovations Methodology

Based on the provided description, here are some potential recommendations for improving access to maternal health:

1. Strengthening healthcare infrastructure: Invest in improving the availability and quality of healthcare facilities, especially in low-income countries. This includes ensuring the availability of essential resources, such as medications, equipment, and trained healthcare professionals.

2. Enhancing infection prevention measures: Implement comprehensive infection prevention and control protocols in healthcare facilities to reduce the risk of maternal infections. This can include measures like proper hand hygiene, sterilization of equipment, and adherence to infection control guidelines.

3. Improving clinical practices: Promote the adoption of evidence-based clinical practices, such as regular monitoring of vital signs (e.g., respiratory rate and pulse oximetry) and timely administration of appropriate interventions (e.g., antibiotics, uterotonics) based on individual clinical needs.

4. Strengthening healthcare capacity: Provide training and education to healthcare providers on maternal health, including the identification and management of infections. This can help improve the overall quality of care provided to pregnant and recently pregnant women.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define outcome measures: Identify specific indicators that reflect improved access to maternal health, such as reduced maternal mortality rates, decreased incidence of maternal infections, increased utilization of healthcare services by pregnant women, or improved compliance with clinical practices.

2. Collect baseline data: Gather data on the current status of maternal health access, including facility resources and services, infection-related maternal outcomes, compliance with clinical practices, and other relevant variables. This can be done through surveys, medical records review, and interviews with healthcare providers and patients.

3. Develop a simulation model: Create a mathematical or statistical model that incorporates the identified recommendations and their potential impact on the outcome measures. This model should consider factors such as the availability of resources, adherence to clinical practices, healthcare capacity, and the socio-economic context of the target population.

4. Input data and run simulations: Input the collected baseline data into the simulation model and run multiple simulations to estimate the potential impact of the recommendations on improving access to maternal health. This can involve varying different parameters, such as the level of implementation of each recommendation or the target population size.

5. Analyze results: Analyze the simulation results to assess the potential benefits and limitations of each recommendation in improving access to maternal health. This can include evaluating the magnitude of the expected improvements, identifying potential challenges or barriers, and exploring trade-offs between different recommendations.

6. Refine and validate the model: Refine the simulation model based on the analysis of the results and incorporate any additional data or insights obtained during the process. Validate the model by comparing the simulated outcomes with real-world data, if available, to assess its accuracy and reliability.

7. Communicate findings and recommendations: Present the findings of the simulation study, including the estimated impact of the recommendations on improving access to maternal health. Use this information to inform policy decisions, resource allocation, and the development of targeted interventions to address the identified gaps.

It is important to note that the methodology for simulating the impact of recommendations may vary depending on the specific context and available data. The above steps provide a general framework that can be adapted and customized accordingly.

Authors & Co-Authors

Statistics:

Citations: 4

Authors: 98

Identifiers:

DOI: 10.1016/S2214-109X(21)00248-5

Research Areas:

Community Interventions, Health System and Policy, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Design:

Case-Control Study, Cohort Study, Cross Sectional Study, Grounded Theory, randomised-control-trial

Study Approach:

Quantitative

Participants Gender:

Female