Risk factors and practices contributing to newborn sepsis in a rural district of Eastern Uganda, August 2013: A cross sectional study

Background: In Uganda, newborn deaths constituted over 38 % of all infant deaths in 2010. Despite different mitigation interventions over years, the newborn mortality rate is high at 27/1,000 and newborn sepsis contributes to 31 % of that mortality. Therefore, improved strategies that contribute to reduction of newborn sepsis need to be developed and implemented. Understanding the context relevant risk factors that determine and practices contributing to newborn sepsis will inform this process. Methodology: A cross sectional study was conducted at Kidera Health Centre in Kidera Sub County, Buyende district between January and August 2013. A total of 174 mothers of sick newborns and 8 health workers were interviewed. Main outcome was newborn sepsis confirmed by blood culture. Independent variables included; mothers’ demographics characteristics, maternal care history and newborn care practices. The odds ratios were used to measure associations and Chi square or Fisher’s exact tests to test the associations. 95 % confidence intervals and P values for the odds ratios were determined. Logistic regression was conducted to identify predictor factors for newborn sepsis. Results: 21.8 % (38/174) of newborns had laboratory confirmed sepsis. Staphylococcus aureus was the commonest aetiological agent. Mothers not screened and treated for infections during antenatal (OR = 3.37; 95 % CI 1.23-9.22) plus inability of sick newborns to breast feed (OR = 3.9; 95 % CI 1.54-9.75) were factors associated with increased likelihood of having laboratory confirmed sepsis. Women not receiving health education during antenatal about care seeking (OR 2.22; 95 % CI 1.07-4.61) and newborn danger signs (OR 2.26; 95 % CI 1.08-4.71) was associated with laboratory confirmed newborn sepsis. The supply of antibiotics and sundries was inadequate to sufficiently control sepsis within health facility. Conclusion: Lack of antenatal care or access to it at health facilities was likely to later result in more sick newborns with sepsis. Poor breastfeeding by sick newborns was a marker for serious bacterial infection. Therefore district sensitization programs should encourage women to attend health facility antenatal care where they will receive health education about alternative feeding practices, screening and treatment for infections to prevent spread of infections to newborns. Supply of antibiotics and sundries should be improved to sufficiently control sepsis within the health facility. This was a cross-sectional study conducted at Kidera Health centre between January and August 2013. Kidera Health Centre is a level four facility located in Kidera County, Buyende District Eastern Uganda. It is the main referral unit for Buyende District. The Health Centre serves the five counties in the district with an estimated population of 248,000 people. The study population was mother and sick newborn pairs admitted at the health facility during the study period. The sick newborns were those admitted with signs and symptoms of sepsis. The definition of neonatal sepsis was adopted from the International Paediatric Sepsis Consensus criteria (PSC) and the Intensive care chapter of Indian Academy of Paediatrics (IAP) [23, 24]. We excluded cases where mothers or newborns were too ill to participate because they had to be referred to Kamuli district hospital for emergency medical care. The estimated sample size using the formula by Kish Leslie (1965), assuming a prevalence of sick newborns with sepsis to be 37 % [25] and a maximum error of 5 % within a 95 % confidence interval was 183 mother and sick newborn pairs. The level of significance was set at p < 0.05. All sick newborns who presented to the health facility were screened for signs and symptoms of sepsis by the health workers. The newborns that fitted the selection criteria for having signs or symptoms of sepsis were moved to the admission ward where the health workers first provided routine investigations and provided treatment according to the national guidelines. After the health workers had provided the treatment, the study team sought informed written consent from the mothers to take part in the study. One of the routine investigations was blood culture to confirm sepsis and determine the aetiological agent. Qualitative data were gathered using a key informant interview question guide for the eight health service providers. They were purposefully selected from the health facility department providing newborn care services and district health team. These included the midwives, nurses and clinical officers at the health facility plus the district focal person for maternal and child health activities. The standard diagnostic test for newborn sepsis in this study was a positive blood culture according to World Health Organization standard guidelines [26]. Blood cultures have a sensitivity that ranges between 80 and 90 % [27, 28]. However in Uganda, most diagnoses for newborn sepsis at lower level facilities (Health Centres) depend on clinical signs and symptoms alone, which results in misclassification of cases [17]. This study used clinical examination to identify the cases and blood culture investigations to confirm the sepsis cases at a Health Centre. The blood cultures identified the aetiological agents while the drug sensitivity tests were done to help determine the appropriate antibiotic treatment regimens to use. The blood samples were collected and processed by a trained district laboratory technician at the health facility. The study provided commercially prepared blood cultures, drug sensitivity discs and an incubator so that the investigations could be done at the health facility. The study used a BBL Septi-Chek manual blood culture system from Dicfo Laboratories. Approximately 2 ml venous blood was obtained after thorough cleansing of the patients’ skin for 2 min with povidine iodine and allowing the skin to dry before taking blood. One millilitre of blood was collected in each of two bottles containing brain heart infusion (BHI) in a ratio of blood: BHI of 1:10 and then taken to the laboratory within 30 min. Each bottle was incubated at 35 °C for 24 h following which it was examined for visible growth and Gram stain was done. Subcultures were done on blood, Chocolate and MacConkey agar from those blood culture bottles which showed presence of bacteria on physical examination and Gram stain. The agar plates were incubated under aerobic conditions [29]. The identification of the microbial isolates was by a combination of physical and biochemical methods that included gram stain, catalase reaction, coagulase reaction, colony morphology and haemolytic activity on blood agar [30]. Oxidase and citrate tests were done for identified gram negative isolates [29]. For a blood cultures which showed no visible growth and was negative on Gram stain, three subcultures were done on blood, Chocolate and MacConkey agar and observed for a maximum of 7 days before being discarded as negative if there was no growth. All culture bottles with mixed growths (defined as more than 2 types of bacteria) were discarded. The disk diffusion method adopted from the Clinical laboratory Institute was used to assess the antimicrobial susceptibility of all the isolates [31]. We used the commonly used antimicrobial agents in the Uganda National treatment guidelines for newborn sepsis to assess the susceptibility of the isolates. Pre-coded, pre-tested, semi-structured questionnaires were used to collect information from the mothers of newborns. The key informant interview (KI) guide was used to interview health providers. The questionnaires and interview guide were pre-tested by the Principal Investigator at Kamuli district hospital. The semi-structured questionnaires were administered by four trained research assistants who were supervised by the Principal Investigator. The questionnaires used to interview mothers of newborn were translated into the local language (Lusoga). The interviews were conducted in the local language and immediately transcribed to English. The Principal investigator and research assistants edited the data collected to ensure completeness and consistency. The data were cleaned and stored by the Principal investigator. The Principal Investigator conducted face to face interviews of health providers using the Key Informant interview guide. The health workers were interviewed to obtain information about challenges in prevention and management of newborn sepsis practices within the facility. The Principal Investigator observed for the availability of equipment and drugs in the facility used in providing appropriate care of newborns. The quantitative data collected using the questionnaire were coded, entered, cleaned using Epi data and exported to SPSS version 16 software where additional variables were created for analysis [32]. The primary outcome was a newborn with laboratory confirmed sepsis. The univariate analysis of demographic factors was carried out using frequencies and means to describe the study participants. Bivariate analysis was done to assess the associations between the primary outcome and the independent exposure variables. The independent variables included; The continuous independent variables were categorized and their association with the primary outcome was established using Chi square tests or Fisher’s exact test (for tables where the expected cell values were less than 5). The measure of association for categorical variables was Odds Ratios. The P values as well as 95 % confidence intervals for the Odds Ratios were determined. Variables found to be significantly associated with laboratory confirmed newborn sepsis at 95 % level in bivariate analysis were included in the multivariate logistic regression analysis using 0.05 for entry and 0.1 for exit P values. Confounding and interaction between the various independent variables was assessed using logistic regression. A stepwise logistic regression model was constructed using a backward elimination approach. Multivariate logistic regression was applied to produce odds ratios of associations between the independent variables and primary outcome of laboratory confirmed sepsis, and adjusted to address the influence of other significant variables. The associations in the multivariate logistic regression analysis that were statistically significant (p > 0.05) were included in the final results. Qualitative data from key informant interviews were transcribed, coded, analysed and separated into themes. It was triangulated with the findings from the questionnaires to gain a deeper understanding of the information observed. The ethical approval was obtained from Makerere University School of Public Health Institutional Review Board, the Higher Degrees and Ethics Committee and the National Council of Science and Technology. Buyende District health authorities and in-charge of Kidera health centre were asked for permission to use their facilities. Informed written consent was obtained from all the participants after explaining the risks and benefits of the study before they were interviewed. We used anonymous identifiers on the questionnaires to ensure privacy of the participants. All the members of the study team complied with good clinical practices.