Incidence of maternal peripartum infection: A systematic review and meta-analysis

Autoři: Susannah L. Woodd aff001;  Ana Montoya aff002;  Maria Barreix aff003;  Li Pi aff004;  Clara Calvert aff001;  Andrea M. Rehman aff001;  Doris Chou aff003;  Oona M. R. Campbell aff001
Působiště autorů: Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom aff001;  Box Hill Hospital, Eastern Health, Victoria, Australia aff002;  Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland aff003;  West China School of Public Health, Sichuan University, Chengdu, China aff004
Vyšlo v časopise: Incidence of maternal peripartum infection: A systematic review and meta-analysis. PLoS Med 16(12): e32767. doi:10.1371/journal.pmed.1002984
Kategorie: Research Article
doi: 10.1371/journal.pmed.1002984



Infection is an important, preventable cause of maternal morbidity, and pregnancy-related sepsis accounts for 11% of maternal deaths. However, frequency of maternal infection is poorly described, and, to our knowledge, it remains the one major cause of maternal mortality without a systematic review of incidence. Our objective was to estimate the average global incidence of maternal peripartum infection.

Methods and findings

We searched Medline, EMBASE, Global Health, and five other databases from January 2005 to June 2016 (PROSPERO: CRD42017074591). Specific outcomes comprised chorioamnionitis in labour, puerperal endometritis, wound infection following cesarean section or perineal trauma, and sepsis occurring from onset of labour until 42 days postpartum. We assessed studies irrespective of language or study design. We excluded conference abstracts, studies of high-risk women, and data collected before 1990. Three reviewers independently selected studies, extracted data, and appraised quality. Quality criteria for incidence/prevalence studies were adapted from the Joanna Briggs Institute. We used random-effects models to obtain weighted pooled estimates of incidence risk for each outcome and metaregression to identify study-level characteristics affecting incidence. From 31,528 potentially relevant articles, we included 111 studies of infection in women in labour or postpartum from 46 countries. Four studies were randomised controlled trials, two were before–after intervention studies, and the remainder were observational cohort or cross-sectional studies. The pooled incidence in high-quality studies was 3.9% (95% Confidence Interval [CI] 1.8%–6.8%) for chorioamnionitis, 1.6% (95% CI 0.9%–2.5%) for endometritis, 1.2% (95% CI 1.0%–1.5%) for wound infection, 0.05% (95% CI 0.03%–0.07%) for sepsis, and 1.1% (95% CI 0.3%–2.4%) for maternal peripartum infection. 19% of studies met all quality criteria. There were few data from developing countries and marked heterogeneity in study designs and infection definitions, limiting the interpretation of these estimates as measures of global infection incidence. A limitation of this review is the inclusion of studies that were facility-based or restricted to low-risk groups of women.


In this study, we observed pooled infection estimates of almost 4% in labour and between 1%–2% of each infection outcome postpartum. This indicates maternal peripartum infection is an important complication of childbirth and that preventive efforts should be increased in light of antimicrobial resistance. Incidence risk appears lower than modelled global estimates, although differences in definitions limit comparability. Better-quality research, using standard definitions, is required to improve comparability between study settings and to demonstrate the influence of risk factors and protective interventions.

Klíčová slova:

Africa – Asia – Europe – Chorioamnionitis – Labor and delivery – Respiratory infections – Sepsis – Systemic inflammatory response syndrome


1. Say L, Chou D, Gemmill A, Tunçalp Ö, Moller A-B, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. The Lancet Global Health. 2014;2(6):e323–e333. doi: 10.1016/S2214-109X(14)70227-X 25103301

2. Bonet M, Pileggi VN, Rijken MJ, Coomarasamy A, Lissauer D, Souza JP, et al. Towards a consensus definition of maternal sepsis: results of a systematic review and expert consultation. Reproductive Health. 2017;14(1):67. doi: 10.1186/s12978-017-0321-6 28558733

3. Hussein J, Walker L. Puerperal sepsis in low and middle income settings: past, present and future. Maternal and Infant Deaths: Chasing Millennium Development Goals. 2010;4:131–147.

4. Lawn JE, Cousens S, Zupan J, Lancet Neonatal Survival Steering Team. 4 million neonatal deaths: When? Where? Why? The Lancet. 2005;365(9462):891–900.

5. Gon G, Leite A, Calvert C, Woodd S, Graham WJ, Filippi V. The frequency of maternal morbidity: A systematic review of systematic reviews. International Journal of Gynecology & Obstetrics. 2018;141:20–38.

6. Dolea C, Stein C. Global burden of maternal sepsis in the year 2000. Evidence and information for policy. Geneva: World Health Organisation; 2003.

7. James SL, Abate D, Abate KH, Abay SM, Abbafati C, Abbasi N, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. The Lancet. 2018;392(10159):1789–1858.

8. WHO. The prevention and management of puerperal infections: report of a technical working group. Geneva: 1992.

9. Centers for Medicare Medicaid Services. ICD-10-CM Official Guidelines for Coding and Reporting FY2019. 2018. [cited 2018 Aug 28]. Available from:

10. Collins Dictionary of Medicine 2004, 2005 [Internet]. S.v. "puerperal sepsis." [cited 2018 Dec 11]. Available from:

11. WHO. WHO recommendations for prevention and treatment of maternal peripartum infections. Geneva: WHO; 2015.

12. Munn Z, Moola S, Lisy K, Riitano D, Tufanaru C. Methodological guidance for systematic reviews of observational epidemiological studies reporting prevalence and cumulative incidence data. International Journal of Evidence-based Healthcare. 2015;13(3):147–153. doi: 10.1097/XEB.0000000000000054 26317388

13. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315(8):801–810. doi: 10.1001/jama.2016.0287 26903338

14. Tita AT, Andrews WW. Diagnosis and management of clinical chorioamnionitis. Clinics in Perinatology. 2010;37(2):339–354. doi: 10.1016/j.clp.2010.02.003 20569811

15. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care–associated infection and criteria for specific types of infections in the acute care setting. American Journal of Infection Control. 2008;36(5):309–332. doi: 10.1016/j.ajic.2008.03.002 18538699

16. Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS international sepsis definitions conference. Intensive Care Medicine. 2003;29(4):530–538. doi: 10.1007/s00134-003-1662-x 12664219

17. Alkaline Software. Alkaline Software; 2015 [cited 2018 Aug 28]. Available from:

18. WHO. International Statistical Classification of Diseases and Related Health Problems 10th Revision 2016 [cited 2018 Aug 28]. Available from:

19. United Nations. [Internet.] SDG Indicators 2017 [cited 2018 Nov 5]. Available from:

20. Schwarzer G. meta: An R package for meta-analysis. R News. 2007;7(3):40–45.

21. Viechtbauer W. Conducting meta-analyses in R with the metafor package. Journal of Statistical Software. 2010;36(3):1–48.

22. Freeman MF, Tukey JW. Transformations related to the angular and the square root. The Annals of Mathematical Statistics. 1950:607–611.

23. Barendregt JJ, Doi SA, Lee YY, Norman RE, Vos T. Meta-analysis of prevalence. J Epidemiol Community Health. 2013;67:974–978. doi: 10.1136/jech-2013-203104 23963506

24. Jackson D, Bowden J, Baker R. How does the DerSimonian and Laird procedure for random effects meta-analysis compare with its more efficient but harder to compute counterparts? Journal of Statistical Planning and Inference. 2010;140(4):961–970.

25. Riley RD, Higgins JP, Deeks JJ. Interpretation of random effects meta-analyses. BMJ. 2011;342:d549. doi: 10.1136/bmj.d549 21310794

26. Chen L, Liu J, Kang Y, Liu J, Sufeng H. [Relationship between pre-pregnant body mass index and pregnancy growth with maternal and neonatal outcomes]. Chongqing Medicine. 2014;43(10):1178–1180.

27. Dong L. [Management and Monitoring Measure of Nosocomial Infection in Cesarean Section, Normal Delivery, Domiciliary Delivery Integral Delivery Room]. Chinese Journal of Nosocomiology. 2009;19(16):39.

28. Dong L, Wang G. [Effect of hand washing method to maternity and infant]. Chinese Journal of Nosocomiology. 2010;20(15):2257–2259.

29. Liu H, Cui Y. [Relationship between body mass index of pregnant women and postpartum incision infection]. Maternal and Child Health Care of China. 2010;25(18):2485–2486.

30. Wang X, Yu X, Qian X. [Postpartum intrauterine infection: clinical features and preventive measures]. Chinese Journal of Nosocomiology. 2010;20(14):2050–2051.

31. Jin Z, Chi X, Teng W, Wang X, Xu Q, Wang P, et al. [Sex hormone-binding globulin of gestational diabetes mellitus pregnant women with well-controlled glucose and pregnancy outcomes]. Zhonghua fu Chan ke za zhi. 2011;46(6):422–426. 21781582

32. Boccardo J, Manzur A, Duarte N, Yanzon C, Mazzanti A, Paparotti L, et al. [Puerperal endometritis in our setting]. Actual SIDA Infectol. 2013;21(80):48–52.

33. Okumura JA, Maticorena DA, Tejeda JE, Mayta-Tristán P. [Teenage pregnancy as a risk factor for obstetric and perinatal complications at a hospital in Lima, Peru]. Revista Brasileira de Saúde Materno Infantil. 2014;14(4):383–392.

34. Sanabria Fromherz ZE, Fernández Arenas C. [Pathologic behavior of puerperium] Revista Cubana de Obstetrícia y Ginecologia. 2011;37(3):330–340.

35. Sánchez JMB, Serrano YP, Soler JRM. [Advanced maternal age as a conducive element in obstetric complications and birth]. Revista de Ciencias Médicas de Pinar del Río. 2015;19(5):789–802.

36. Benincasa BC, Walker C, Cioba C, Rosa CCdS, Martins DE, Oliveira EDAd, et al. [Rates of infection related to cesarean and vaginal delivery at HCPA]. Revista HCPA Porto Alegre. 2012;32(1):5–9.

37. Luz AG, Tiago DB, Silva JCGd, Amaral E. [Severe maternal morbidity at a local reference university hospital in Campinas, São Paulo, Brazil]. Revista Brasileira de Ginecologia e Obstetrícia. 2008;30(6):281–286. doi: 10.1590/s0100-72032008000600003 19142505

38. Péret FJA, Melo VH, Paula LBd, Andrade BAMd, Pinto JA. [Puerperal morbidity in HIV-infected and non-infected women]. Revista Brasileira de Ginecologia e Obstetricia. 2007;29(5):260–266.

39. Petter CE, Farret TCF, de Souza Scherer J, Antonello VS. [Factors related to surgical site infections after obstetric procedures]. Scientia Medica. 2013;23(1):5.

40. Ben SH, Khoudayer H, Ben HZ, Masmoudi A, Bouguerra B, Sfar R. [Severe maternal morbidity]. Journal de Gynecologie, Obstetrique et Biologie de la Reproduction. 2007;36(7):694–698. doi: 10.1016/j.jgyn.2007.05.006 17574775

41. Mayi-Tsonga S, Meyé J-F, Tagne A, Ndombi I, Diallo T, Oksana L, et al. [Audit of the severe obstetrical morbidity (near miss) in Gabon]. Cahiers d'Etudes et de Recherches Francophones/Santé. 2007;17(2):111–115.

42. Saizonou J, Ouédraogo L, Paraiso MN, Ayélo P, Kpozèhouen A, Daraté R, et al. [Epidemiology and management of intrapartum infections in the maternity ward of Ouémé-Plateau county hospital in Benin]. The Pan African Medical Journal. 2014;17:89. doi: 10.11604/pamj.2014.17.89.2857 25120854

43. Ivanov S, Tzvetkov K, Kovachev E, Staneva D, Nikolov D. [Puerperal infections after Cesarean section and after a natural childbirth]. Akusherstvo i Ginekologiia. 2014;53:25–28.

44. Marić T, Tomić V, Darko K. [Puerperal complications in nulliparous women delivered by section caesarean: pair study]. Medicinski Arhiv. 2006;60(4):246–250. 16761520

45. Dimitriu G. [Clinical statistical study on puerperal sepsis risk factors]. Revista Medico-chirurgicala a Societatii de Medici si Naturalisti din Iasi. 2010;114(1):195–198. 20509301

46. Abramovici A, Szychowski JM, Biggio JR, Sakawi Y, Andrews WW, Tita AT. Epidural use and clinical chorioamnionitis among women who delivered vaginally. American Journal of Perinatology. 2014;31(11):1009–1014. doi: 10.1055/s-0034-1371357 24705965

47. Jokhio AH, Winter HR, Cheng KK. An intervention involving traditional birth attendants and perinatal and maternal mortality in Pakistan. New England Journal of Medicine. 2005;352(20):2091–2099. doi: 10.1056/NEJMsa042830 15901862

48. Kovavisarach E, Jirasettasiri P. Randomised controlled trial of perineal shaving versus hair cutting in parturients on admission in labor. J Med Assoc Thai. 2005;88(9):1167. 16536100

49. Bakr AF, Karkour T. Effect of predelivery vaginal antisepsis on maternal and neonatal morbidity and mortality in Egypt. Journal of Women's Health. 2005;14(6):496–501. doi: 10.1089/jwh.2005.14.496 16115003

50. Cavazos-Rehg PA, Krauss MJ, Spitznagel EL, Bommarito K, Madden T, Olsen MA, et al. Maternal age and risk of labor and delivery complications. Maternal and Child Health Journal. 2015;19(6):1202–1211. doi: 10.1007/s10995-014-1624-7 25366100

51. Dumas A-M, Girard R, Ayzac L, Beaumont G, Caillat-Vallet E, Depaix F, et al. Effect of intrapartum antibiotic prophylaxis against group B streptococcal infection on comparisons of rates of endometritis and urinary tract infection in multicenter surveillance. Infection Control & Hospital Epidemiology. 2008;29(4):327–332.

52. Getahun D, Strickland D, Zeiger RS, Fassett MJ, Chen W, Rhoads GG, et al. Effect of chorioamnionitis on early childhood asthma. Archives of Pediatrics & Adolescent Medicine. 2010;164(2):187–192.

53. Kyser KL, Lu X, Santillan DA, Santillan MK, Hunter SK, Cahill AG, et al. The association between hospital obstetrical volume and maternal postpartum complications. American Journal of Obstetrics and Gynecology. 2012;207(1):42.e1–17.

54. Lyndon A, Lee HC, Gilbert WM, Gould JB, Lee KA. Maternal morbidity during childbirth hospitalization in California. The Journal of Maternal-Fetal & Neonatal Medicine. 2012;25(12):2529–2535.

55. Malloy M. Chorioamnionitis: epidemiology of newborn management and outcome United States 2008. Journal of Perinatology. 2014;34(8):611. doi: 10.1038/jp.2014.81 24786381

56. Rücker G, Schwarzer G, Carpenter JR, Schumacher M. Undue reliance on I2 in assessing heterogeneity may mislead. BMC Medical Research Methodology. 2008;8(1):79.

57. Bleich AT, Alexander JM, McIntire DD, Leveno KJ. An analysis of second-stage labor beyond 3 hours in nulliparous women. American Journal of Perinatology. 2012;29(09):717–722.

58. Fronczak N, Antelman G, Moran A, Caulfield L, Baqui A. Delivery‐related complications and early postpartum morbidity in Dhaka, Bangladesh. International Journal of Gynecology & Obstetrics. 2005;91(3):271–278.

59. Ghani N, Rukanuddin RJ, Ali TS. Prevalence and factors associated with postpartum vaginal infection in the Khyber agency federally administered tribal areas, Pakistan. Journal of Pakistan Medical Association. 2007;57(7):363.

60. Gözüm S, Kiliç D. Health problems related to early discharge of Turkish women. Midwifery. 2005;21(4):371–378. doi: 10.1016/j.midw.2005.02.005 16024147

61. Shriraam V, Shah P, Rani M, Palani G, Sathiyasekaran B. Postpartum morbidity and health seeking pattern in a rural community in South India–population based study. Indian Journal of Maternal and Child Health. 2012;14(3):10.

62. Andersson N, Omer K, Caldwell D, Dambam MM, Maikudi AY, Effiong B, et al. Male responsibility and maternal morbidity: a cross-sectional study in two Nigerian states. BMC Health Services Research. 2011;11(2):S7.

63. Suthee Panichkul M, Boonprasert K, Komolpis S, Panichkul P. The association between meconium-stained amniotic fluid and chorioamnionitis or endometritis. J Med Assoc Thai. 2007;90(3):442–447. 17427518

64. Al‐Ostad G, Kezouh A, Spence AR, Abenhaim HA. Incidence and risk factors of sepsis mortality in labor, delivery and after birth: Population‐based study in the USA. Journal of Obstetrics and Gynaecology Research. 2015;41(8):1201–1206. doi: 10.1111/jog.12710 25976287

65. Dotters-Katz S, Patel E, Grotegut C, Heine R. Acute infectious morbidity in multiple gestation. Infectious Diseases in Obstetrics and Gynecology. 2015;2015:173261. doi: 10.1155/2015/173261 25684973

66. Caughey AB, Stotland NE, Washington AE, Escobar GJ. Maternal and obstetric complications of pregnancy are associated with increasing gestational age at term. American Journal of Obstetrics and Gynecology. 2007;196(2):155.e1–6.

67. Braun D, Bromberger P, Ho NJ, Getahun D. Low rate of perinatal sepsis in term infants of mothers with chorioamnionitis. American Journal of Perinatology. 2016;33(02):143–150.

68. Edwards SE, Grobman WA, Lappen JR, Winter C, Fox R, Lenguerrand E, et al. Modified obstetric early warning scoring systems (MOEWS): validating the diagnostic performance for severe sepsis in women with chorioamnionitis. American Journal of Obstetrics and Gynecology. 2015;212(4):536.e1–8.

69. Cheng YW, Shaffer BL, Bryant AS, Caughey AB. Length of the first stage of labor and associated perinatal outcomes in nulliparous women. Obstetrics & Gynecology. 2010;116(5):1127–1135.

70. Ayzac L, Caillat-Vallet E, Girard R, Chapuis C, Depaix F, Dumas A-M, et al. Decreased rates of nosocomial endometritis and urinary tract infection after vaginal delivery in a French surveillance network, 1997–2003. Infection Control & Hospital Epidemiology. 2008;29(6):487–495.

71. King JR, Korst LM, Miller DA, Ouzounian JG. Increased composite maternal and neonatal morbidity associated with ultrasonographically suspected fetal macrosomia. The Journal of Maternal-Fetal & Neonatal Medicine. 2012;25(10):1953–1959.

72. Bauer ME, Bateman BT, Bauer ST, Shanks AM, Mhyre JM. Maternal sepsis mortality and morbidity during hospitalization for delivery: temporal trends and independent associations for severe sepsis. Anesthesia & Analgesia. 2013;117(4):944–950.

73. Acosta CD, Knight M, Lee HC, Kurinczuk JJ, Gould JB, Lyndon A. The continuum of maternal sepsis severity: incidence and risk factors in a population-based cohort study. PLoS ONE. 2013;8(7):e67175. doi: 10.1371/journal.pone.0067175 23843991

74. Tippawan Liabsuetrakul M, Suchonwanich Y. Birth rates and pregnancy complications in adolescent pregnant women giving birth in the hospitals of Thailand. J Med Assoc Thai. 2014;97(8):785–790. 25345252

75. Callaghan WM, MacKay AP, Berg CJ. Identification of severe maternal morbidity during delivery hospitalizations, United States, 1991–2003. American Journal of Obstetrics and Gynecology. 2008;199(2):133.e1–8.

76. Leth RA, Møller JK, Thomsen RW, Uldbjerg N, Nørgaard M. Risk of selected postpartum infections after cesarean section compared with vaginal birth: A five‐year cohort study of 32,468 women. Acta Obstetricia et Gynecologica Scandinavica. 2009;88(9):976–983. doi: 10.1080/00016340903147405 19642043

77. Knowles S, O'sullivan N, Meenan A, Hanniffy R, Robson M. Maternal sepsis incidence, aetiology and outcome for mother and fetus: a prospective study. BJOG: An International Journal of Obstetrics & Gynaecology. 2015;122(5):663–671.

78. Liu S, Liston RM, Joseph K, Heaman M, Sauve R, Kramer MS. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. CMAJ. 2007;176(4):455–460. doi: 10.1503/cmaj.060870 17296957

79. Kuklina EV, Whiteman MK, Hillis SD, Jamieson DJ, Meikle SF, Posner SF, et al. An enhanced method for identifying obstetric deliveries: implications for estimating maternal morbidity. Maternal and Child Health Journal. 2008;12(4):469–477. doi: 10.1007/s10995-007-0256-6 17690963

80. Palmer WL, Bottle A, Aylin P. Association between day of delivery and obstetric outcomes: observational study. BMJ. 2015;351:h5774. doi: 10.1136/bmj.h5774 26602245

81. Guendelman S, Thornton D, Gould J, Hosang N. Obstetric complications during labor and delivery: assessing ethnic differences in California. Women's Health Issues. 2006;16(4):189–197. doi: 10.1016/j.whi.2005.12.004 16920523

82. Goff SL, Pekow PS, Avrunin J, Lagu T, Markenson G, Lindenauer PK. Patterns of obstetric infection rates in a large sample of US hospitals. American Journal of Obstetrics and Gynecology. 2013;208(6):456.e1–13.

83. Vos T, Allen C, Arora M, Barber RM, Bhutta ZA, Brown A, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet. 2016;388(10053):1545.

84. United Nations DESA/Population Division. World Population Prospects 2017 [Internet]. 2017 [cited 2019 May 9]. Available from:

85. Sway A, Nthumba P, Solomkin J, Tarchini G, Gibbs R, Ren Y, et al. Burden of surgical site infection following cesarean section in sub-Saharan Africa: a narrative review. International Journal of Women's Health. 2019;11:309. doi: 10.2147/IJWH.S182362 31191039

86. Sobhy S, Arroyo-Manzano D, Murugesu N, Karthikeyan G, Kumar V, Kaur I, et al. Maternal and perinatal mortality and complications associated with caesarean section in low-income and middle-income countries: a systematic review and meta-analysis. The Lancet. 2019;393(10184):1973–1982.

87. Bianco A, Roccia S, Nobile CG, Pileggi C, Pavia M. Postdischarge surveillance following delivery: the incidence of infections and associated factors. American Journal of Infection Control. 2013;41(6):549–553. doi: 10.1016/j.ajic.2012.06.011 23219668

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