Post cesarean section surgical site infection and associated factors among women who delivered in public hospitals in Harar city, Eastern Ethiopia: A hospital-based analytic cross-sectional study

  • PLoS ONE, Volume 16, No. 6 June, Year 2021

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Study Justification:
The study aimed to estimate the prevalence of surgical site infection (SSI) and identify the factors associated with SSI among women who underwent cesarean section (CS) in public hospitals in Harar city, Eastern Ethiopia. This research is important because CS is often complicated by SSI, which can lead to maternal morbidity and increased healthcare costs. By understanding the prevalence and associated factors of SSI, healthcare providers and policymakers can implement targeted interventions to prevent and manage SSI in this population.
Highlights:
– The prevalence of SSI among women who underwent CS in public hospitals in Harar city was found to be 12.3%.
– Factors significantly associated with post-CS SSI included general anesthesia, rupture of membrane, hospital stay for over 7 days after the operation, and blood transfusion.
– Screening for preoperative anemia and appropriate correction before surgery, selection of the type of anesthesia, close follow-up to avoid unnecessary prolonged hospitalization, and careful assessment of membrane status were recommended to prevent SSI and maternal morbidity.
Recommendations:
Based on the study findings, the following recommendations are made:
1. Implement preoperative screening for anemia and provide appropriate correction before CS surgery.
2. Consider the type of anesthesia carefully, taking into account the risk of SSI.
3. Ensure close follow-up of patients to avoid unnecessary prolonged hospitalization.
4. Conduct careful assessment of membrane status before CS surgery.
5. Develop and implement infection prevention and control protocols specific to CS procedures in public hospitals.
Key Role Players:
1. Gynecology and obstetrics senior specialists
2. Residents
3. Integrated emergency surgical officers
4. Medical directors of public hospitals
5. Healthcare providers involved in CS procedures
6. Hospital administrators
7. Ethical review committee members
8. Researchers and data collectors
Cost Items for Planning Recommendations:
1. Training and capacity building for healthcare providers on infection prevention and control protocols: includes costs for organizing workshops, materials, and trainers.
2. Preoperative screening for anemia: includes costs for laboratory tests and equipment.
3. Selection and procurement of appropriate anesthesia supplies: includes costs for anesthesia drugs and equipment.
4. Follow-up and monitoring systems: includes costs for developing and implementing systems to track patient progress and identify potential complications.
5. Infection prevention and control protocols: includes costs for developing and disseminating protocols, training healthcare providers, and monitoring compliance.
6. Research and data collection: includes costs for data collection tools, data entry, and analysis.
7. Implementation of recommendations: includes costs for infrastructure improvements, equipment, and supplies needed to support the recommended interventions.
Please note that the cost items provided are for planning purposes and may vary depending on the specific context and resources available.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is relatively strong, but there are some areas for improvement. The study design is a hospital-based analytic cross-sectional study, which provides valuable information but does not establish causality. The sample size of 1069 women is relatively large, which increases the reliability of the findings. The prevalence of post-CS SSI is reported with a 95% confidence interval, indicating the precision of the estimate. The factors associated with SSI are identified using multivariable binary logistic regression analysis, which helps control for confounding variables. However, there are some limitations to consider. The data collection method relies on reviewing medical records, which may introduce bias or incomplete information. The study setting is limited to two public hospitals in Harar city, Eastern Ethiopia, which may not be representative of the entire population. To improve the evidence, future studies could consider a prospective design to establish causality and include a larger and more diverse sample. Additionally, using standardized data collection tools and ensuring complete and accurate documentation of variables would enhance the reliability of the findings.

Background Cesarean section (CS) is often complicated by surgical site infection (SSI) that may happen to a woman within 30 days after the operation. This study was conducted to estimate the prevalence of SSI and identify the factors associated with SSI. Methods A hospital-based analytic cross-sectional study was conducted based on the review of medical records of 1069 women who underwent CS in two public hospitals in Harar city. The post-CS SSI is defined when it occurred within 30 days after the CS procedure. Factors associated with SSI were identified using a multivariable binary logistic regression analysis. The analysis outputs are presented using an adjusted odds ratio (aOR) with a corresponding 95% confidence interval (CI). All statistical tests are defined as statistically significant at P-values<0.05. Results The prevalence of SSI was 12.3% (95% confidence interval (CI): 10.4, 14.4). Emergency- CS was conducted for 75.9% (95% CI: 73.2, 78.3) of the women and 13.2% (95% CI: 11.3, 15.4) had at least one co-morbid condition. On presentation, 21.7% (95% CI: 19.3, 24.3) of women had rupture of membrane (ROM). Factors significantly and positively associated with post-CS SSI include general anesthesia (aOR = 2.0, 95%CI: 1.10, 2.90), ROM (aOR = 2.27, 95%CI: 1.02, 3.52), hospital stay for over 7 days after operation (aOR = 3.57, 95%CI: 1.91, 5.21), and blood transfusion (aOR = 4.2, 95%CI: 2.35, 6.08). Conclusion The prevalence of post-CS SSI was relatively high in the study settings. Screening for preoperative anemia and appropriate correction before surgery, selection of the type of anesthesia, close follow-up to avoid unnecessary prolonged hospitalization, and careful assessment of membrane status should be considered to avoid preventable SSI and maternal morbidity. Copyright:

A fifteen months data, from October 11, 2018 to December 31, 2019, was extracted from patient records during March 1 to March 15, 2020 from two public hospitals in Harar city, namely Jugol General Hospital and Hiwot Fana Specialized University Hospital (HFSUH), Eastern Ethiopia. Harar city is located at 526 km towards the east of Addis Ababa, the Ethiopian capital. According to the 2007 census conducted by the Central Statistical Agency, the total population of the region is estimated to be 183, 415 [15]. Ethiopia’s health service is structured into a three tier system: primary healthcare unit (health post (serve 3000–5000 people), health center (serve 15000–40,000 people), and primary hospital (serve 60,000–100,000 people)), secondary level healthcare (general hospital: serve 1.0–1.5 million people), and tertiary level healthcare (specialized hospital: 3.0–5.0 million people). When this study was conducted, there were two public hospitals (general and specialized hospitals), two private general hospitals, one police-, and one non-governmental fistula hospital in the region. In addition to these hospitals in the city, there were 29 private clinics, 26 health posts, eight health centers, and one regional laboratory. In the two hospitals, in terms of human resource to provide CS services, there were 7 gynecology and obstetrics senior specialists, 33 residents, and 3 integrated emergency surgical officers (only in Jugol General Hospital). Hospital-based analytic cross-sectional audit of patient records (from October 11, 2018 to December 31, 2019) was conducted to estimate the magnitude of post-CS SSI and identify the associated factors among women who underwent CS in two public hospitals. The source population for this study was all women who underwent CS at the public hospitals in Harar city. Those women for whom CS procedure was conducted in the specified period are considered as our study population. We reviewed all the medical records of women who underwent CS in the specified period. Medical records with incomplete values for the outcome and important predictor variables were excluded. We conducted a census of all cesarean sections conducted in the two hospitals during the period of October 11, 2018 to December 31, 2019. Over this period, we found 1069 complete medical records documented with CS birth (806 records from HFSUH and 263 from Jugal General Hospital). We identified records of eligible women by reviewing hospital registry books in the operation room and at labor and obstetric wards. Data collection checklists are developed after reviewing variables in patient’s medical records. Five diploma midwives working at the study hospitals reviewed patient medical records and collected data using the data collection checklists. Two senior midwives, one at each hospital, supervised data collection process, and the principal investigator closely oversaw the overall data collection activity. The data collected included variables on characteristics related to demography, obstetrics, operation, comorbidity, and a post-CS SSI status. Age and residence are the only demographic characteristics for which values are collected. Data on obstetrics characteristics included parity (which refers to the number of pregnancies carried to fetal viability), gestational age (measured in weeks from last menstrual period to the date of CS), presence of labor before operation, duration of labor, membrane status before operation, duration of membrane rapture before operation, and chorioamnionitis (an inflammation of the fetal membranes, amnion and chorion, mostly due to bacterial infection). Regarding comorbidity data on cardiac disease, diabetes mellitus, hypertension, Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS), and anemia are collected. Variables collected to characterize the CS operation were the professional level of a physician conducting the operation, operation type (elective versus emergency: a CS is emergency operation when it was done due to unexpected or acute obstetric emergencies, when the mother’s or fetus’s life or well-being is in direct jeopardy or risk [16]), duration of the operation, type of anesthesia (regional versus general), prophylactic antibiotic, duration of the operation, pre-operation hematocrit count, blood transfusion, type of abdominal incision (lower transverse versus vertical), and post-operation hospital stay in days), and a post-CS SSI status which was defined according to the Center for Disease Control and Prevention’s (CDC) standard [5]. Post-CS SSI was the outcome variable and measured using five items with a yes/no response. The items used include: fever≥38°C, purulent discharge from surgical site, at least one sign of inflammation (pain/tenderness, localized swelling, redness or heat), abscess, and diagnosed wound infection by a physician/surgeon. A post-CS SSI was defined if there was at least one ‘yes’ response to any of the five items within 30 days after operation [5]. The data were entered into Epi-data version 3.1 and exported to Stata version 16 software for analysis. Descriptive data analysis was made using frequency and percentages. Difference of proportion between two samples was conducted to see if there is a significant difference in the proportion of post-CS SSI between population groups. Bivariable and multivariable binary logistic regression analyses were conducted to identify factors associated with post-CS SSI. Variables that showed statistically significant association (p<0.25) in the bivariable binary logistic regression are entered in the multivariable model. Model fitness of the final model was checked using the Hosmer-Lemeshow test in Stata (post-estimation command: estat gof) and it demonstrated a good fit with Pearson chi2 (133) = 149.7 and P-value = 0.153. Adjusted odds ratio (aOR) along with 95% CI was estimated to identify factors associated with post-CS SSI. Multicollinearity was checked using variance inflation factor (VIF) (higher VIF suggests possible existence of collinearity), and we removed a variable, ‘presence of anemia’, which showed collinearity with another variable, ‘co-morbid conditions’. Statistical estimates were considered as significant at P-value < 0.05. This study obtained ethical approval from the Haramaya University, College of Health and Medical Sciences, Institutional Health Research Ethics Review Committee (IHRERC) with a reference number of IHRERC/016/2020. Formal letters of permission were written from the College to administrators of both Jugol General Hospital and HFSUH. Data collection was started after obtaining informed, written, voluntary and signed consent from the medical directors of the two hospitals involved. The ethics review committee waived obtaining informed consent from patients to access data. We collected the data anonymously without patient identifying information to maintain confidentiality of patient information.

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

1. Telemedicine: Implementing telemedicine services can provide remote access to healthcare professionals, allowing pregnant women to receive medical advice, consultations, and follow-up care without the need for in-person visits.

2. Mobile health applications: Developing mobile applications that provide educational resources, reminders for prenatal care appointments, and personalized health information can empower pregnant women to take an active role in their own healthcare.

3. Community health workers: Training and deploying community health workers who can provide basic prenatal care, education, and support to pregnant women in remote or underserved areas can help improve access to maternal health services.

4. Transportation solutions: Addressing transportation barriers by providing affordable and reliable transportation options for pregnant women to reach healthcare facilities can ensure timely access to prenatal care and emergency obstetric services.

5. Maternal health clinics: Establishing dedicated maternal health clinics in areas with high maternal mortality rates can provide comprehensive prenatal care, delivery services, and postpartum support, ensuring that women receive the care they need in a safe and supportive environment.

6. Health education campaigns: Conducting targeted health education campaigns to raise awareness about the importance of prenatal care, safe delivery practices, and postpartum care can help improve maternal health outcomes by encouraging women to seek timely and appropriate care.

7. Collaborative partnerships: Building partnerships between healthcare providers, community organizations, and government agencies can help leverage resources and expertise to improve access to maternal health services, especially in resource-limited settings.

It is important to note that the specific context and needs of the community should be taken into consideration when implementing these innovations to ensure their effectiveness and sustainability.
AI Innovations Description
Based on the provided description, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Implement a preoperative screening process: Develop a standardized preoperative screening process to identify women at risk of surgical site infection (SSI) after cesarean section (CS). This process should include screening for anemia and other comorbid conditions, such as cardiac disease, diabetes mellitus, hypertension, HIV/AIDS, and anemia. By identifying these risk factors before surgery, healthcare providers can take appropriate measures to prevent SSI and improve maternal outcomes.

2. Improve anesthesia selection: Consider the type of anesthesia used during CS procedures. General anesthesia was found to be significantly associated with post-CS SSI. Explore the possibility of using regional anesthesia, such as epidural or spinal anesthesia, as an alternative to general anesthesia whenever appropriate. This can help reduce the risk of SSI and improve recovery outcomes for women undergoing CS.

3. Enhance postoperative care and follow-up: Implement a system for close follow-up and monitoring of women after CS procedures to avoid unnecessary prolonged hospitalization. This can help prevent complications and reduce the risk of SSI. Develop protocols for assessing and managing postoperative complications, including wound infections, to ensure timely intervention and appropriate treatment.

4. Educate healthcare providers: Provide training and education to healthcare providers, including gynecology and obstetrics specialists, residents, and midwives, on best practices for preventing SSI after CS. This should include proper surgical techniques, infection control measures, and postoperative care protocols. Regular updates and refresher courses can help ensure that healthcare providers are equipped with the latest knowledge and skills to provide high-quality maternal care.

5. Strengthen healthcare infrastructure: Invest in improving the healthcare infrastructure, including staffing and resources, in public hospitals. This can help ensure adequate capacity to handle CS procedures and provide optimal care to women. Consider increasing the number of gynecology and obstetrics specialists, residents, and integrated emergency surgical officers to meet the demand for CS services. Additionally, ensure the availability of necessary equipment, supplies, and medications for safe and effective CS procedures.

By implementing these recommendations, access to maternal health can be improved, and the prevalence of post-CS SSI can be reduced, leading to better maternal outcomes and overall healthcare quality.
AI Innovations Methodology
Based on the provided description, here are some potential recommendations to improve access to maternal health:

1. Strengthen preoperative screening: Implement a standardized protocol for preoperative screening to identify and address potential risk factors for surgical site infection (SSI), such as anemia. This could involve routine blood tests and appropriate correction of any identified deficiencies before surgery.

2. Improve anesthesia selection: Develop guidelines for selecting the type of anesthesia for cesarean sections (CS) to minimize the risk of SSI. Consider regional anesthesia as a preferred option over general anesthesia whenever possible, as it has been associated with a lower risk of SSI.

3. Enhance postoperative care and follow-up: Implement a system for close follow-up and monitoring of women who have undergone CS to avoid unnecessary prolonged hospitalization. This could involve regular assessments of wound healing, infection surveillance, and timely discharge planning.

4. Promote infection prevention practices: Develop and implement infection prevention protocols in the hospitals, including proper hand hygiene, sterile techniques during surgery, and appropriate use of prophylactic antibiotics. This could help reduce the risk of SSI and improve overall maternal health outcomes.

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

1. Define the target population: Identify the specific population that will be affected by the recommendations, such as women undergoing CS in public hospitals in Harar city, Eastern Ethiopia.

2. Collect baseline data: Gather relevant data on the prevalence of SSI, associated factors, and current access to maternal health services in the target population. This could involve reviewing medical records, conducting surveys, and analyzing existing data sources.

3. Develop a simulation model: Create a mathematical or statistical model that incorporates the identified recommendations and their potential impact on access to maternal health. This model should consider factors such as the reduction in SSI rates, improved postoperative care, and increased availability of resources.

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. This could involve varying parameters, such as the implementation rate of each recommendation and the population coverage.

5. Analyze results: Analyze the simulation results to assess the projected impact of the recommendations on improving access to maternal health. This could include evaluating changes in SSI rates, maternal morbidity, hospital stay duration, and other relevant indicators.

6. Validate and refine the model: Validate the simulation model by comparing the projected results with real-world data, if available. Refine the model as needed to improve its accuracy and reliability.

7. Communicate findings and make recommendations: Summarize the simulation results and communicate them to relevant stakeholders, such as healthcare providers, policymakers, and researchers. Use the findings to make evidence-based recommendations for improving access to maternal health in the target population.

It is important to note that the methodology described above is a general framework and may need to be adapted based on the specific context and available data.


Statistics:
Citations: 1
Identifiers:
DOI: 10.1371/journal.pone.0253194
Research Areas:
Community Interventions, Health System and Policy, Infectious Diseases, Maternal and Child Health, Noncommunicable Diseases, Quality of Care, Sexual and Reproductive Health, Social Determinants, Workforce
Study Countries:
Ethiopia
Study Design:
Case-Control Study, Cohort Study, Cross Sectional Study, Grounded Theory
Study Approach:
Quantitative
Participants Gender:
Female
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