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Lancet Infect Dis. Author manuscript; available in PMC 2010 April 20.
Published in final edited form as:
PMCID: PMC2856817

Maternal and early onset neonatal bacterial sepsis: burden and strategies for prevention in sub-Saharan Africa


Maternal and child health are high priorities for international development. Through a Review of published work, we show substantial gaps in current knowledge on incidence (cases per live births), aetiology, and risk factors for both maternal and early onset neonatal bacterial sepsis in sub-Saharan Africa. Although existing published data suggest that sepsis causes about 10% of all maternal deaths and 26% of neonatal deaths, these are likely to be considerable underestimates because of methodological limitations. Successful intervention strategies in resource-rich settings and early studies in sub-Saharan Africa suggest that the burden of maternal and early onset neonatal bacterial sepsis could be reduced through simple interventions, including antiseptic and antibiotic treatment. An effective way to expedite evidence to guide interventions and determine the incidence, aetiology, and risk factors for sepsis in sub-Saharan Africa would be through a multiarmed factorial intervention trial aimed at reducing both maternal and early onset neonatal bacterial sepsis in sub-Saharan Africa.


Millennium development goals (MDGs) four and five identify maternal and child health as high priorities for international development.1 The greatest unmet need is in sub-Saharan Africa,2,3 accounting for half of all maternal and child deaths worldwide. In all the countries reported in sub-Saharan Africa, except Eritrea, insufficient or no progress in reducing child mortality has been made between 1990 and 2005 to achieve MDG four (a two-thirds reduction in childhood mortality rates between 1990 and 2015).4 Equivalent longitudinal data on maternal mortality to identify progress towards MDG five (a reduction in the maternal mortality ratio by three-quarters between 1990 and 2015) is unavailable. However, maternal mortality (measured as maternal mortality ratio) remains high or very high.4,5 Maternal mortality ratio is defined as the annual number of female deaths from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth, or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, for a specified year.2 In 2005, WHO estimated the maternal mortality ratio as 900 per 100 000 live births in sub-Saharan Africa, 100-times the maternal mortality ratio of resource-rich countries (nine per 100 000 live births).2 The neonatal mortality rate—defined as the number of babies dying in the neonatal period (first 28 days of life) per 1000 live births6—was estimated as 44 per 1000 live births, four times the rate in Europe (11 per 1000 births) and the Americas (12 per 1000 births).6 Of these neonatal deaths, three-quarters occur early (within 7 days of birth). Additionally, stillbirths are thought to equal the number of neonatal deaths worldwide.6

This Review aims to describe the burden of sepsis contributing to maternal and early onset neonatal morbidity and mortality in sub-Saharan Africa, and the evidence for potential interventions. The close relationship between mothers and their infants results in shared aetiologies and risk factors for infectious diseases, HIV being the most recently highlighted.7-10 In resource-rich countries, interventions such as risk-based antibiotic prophylaxis (based on microbiological screening or risk factors in pregnancy) have been highly effective in reducing both early onset neonatal bacterial11 and maternal sepsis.12 Consequently, 15% of all neonatal deaths in countries with low neonatal mortality rates (less than five per 1000 live births in countries such as the UK and USA) are from infection, diarrhoea, or both, but 34% of all neonatal deaths in countries with high neonatal mortality rates (more than 44 per 1000 live births in countries such as the Democratic Republic of Congo and Nigeria) are from these causes.13

Current research in resource-rich countries aims to further reduce neonatal sepsis through the development of maternal vaccines against prevalent pathogens, such as Streptococcus agalactiae (group B streptococcus).14 However, in sub-Saharan Africa research has generally focused on either child or maternal health, and there are likely to be opportunities for simple preventive measures affecting both. These could be based on improving health systems and new approaches identified through improved epidemiology and subsequent intervention trials.

Given the very high maternal and neonatal mortality rates in sub-Saharan Africa, and the effectiveness of simple interventions to prevent maternal and early onset neonatal bacterial sepsis shown elsewhere, identifying research priorities and developing strategies to prevent maternal and early onset neonatal bacterial sepsis in sub-Saharan Africa is essential.

Incidence of maternal sepsis

WHO defines puerperal sepsis as infection of the genital tract occurring at any time between the onset of the rupture of membranes or labour and the 42nd day post partum in which fever and one or more of the following are present: pelvic pain, abnormal vaginal discharge, abnormal odour of discharge, and delay in the rate of reduction of size of the uterus.15 The term maternal sepsis is used in this Review to include all infections in the same period.

Most estimates of puerperal sepsis in sub-Saharan Africa come from retrospective studies of maternal deaths, without microbiological investigation. Thus, these data reflect the burden of clinically defined puerperal sepsis as a cause of death, rather than the actual incidence (cases per live births) of puerperal sepsis or other important infections in the population.

A 2006 WHO systematic review of the causes of maternal deaths worldwide16 estimated that 9·7% (95% CI 6·3–12·6) of maternal deaths in Africa were due to puerperal sepsis. The datasets (since 1990) were selected to be representative of their populations and selected by methodological quality against predetermined criteria. Nine studies from Africa were included, and eight of these were from sub-Saharan Africa. All concerned a single country or region, retrospectively reviewing maternal deaths,17-23 except one, which was a multinational, prospective, population-based study in six countries in west Africa recruiting and following up 19 545 pregnant women.24 In this study, maternal deaths were followed up by analysis of medical records and by verbal autopsy. Six maternal deaths were attributed to sepsis, accounting for 10·9% of all maternal deaths or 33·9 (12·4–73·8) deaths per 100 000 live births.24 The wide CIs reflect the difficulty of using maternal death as a prospective outcome, even in a multinational study. Retrospective case reviews, however, are hampered by poor documentation and limited investigations, which reduce the accuracy of these reports. Many maternal deaths are unrecorded, particularly if delivery occurs outside of a hospital.

Since the WHO systematic review, a South African confidential enquiry25 into maternal deaths (representative of the population it described) reported puerperal sepsis as the cause of 8·3% (274) of deaths (2002–04). The diagnosis of puerperal sepsis was separated from non-pregnancy related infections, which accounted for 23·0% (130) of maternal deaths in 1998,21 increasing to 37·8% (1246) of maternal deaths in 2002–04.25 Of these deaths, 53·1% (662) were attributed to HIV/AIDS, 25·4% (316) to pneumonia, 8·3% (104) to tuberculosis, and 6·3% (79) to meningitis. Diagnoses were clinical, rather than from systematic microbiological investigation.

An important recent study comes from a tertiary facility in Mozambique;26 although not population-based (referral centre), it is included here as the first prospective study in sub-Saharan Africa to use autopsy and histology to determine the cause of maternal death. From 139 autopsies, 14 (10·1%) were puerperal or post-caesarean sepsis. Additionally, 67 (48·2%) deaths were from other infectious diseases (table 1). Using the data from this study, a retrospective review has since been carried out to assess the correlation between autopsy (used as gold-standard for cause of death) and prior clinical diagnosis of maternal cause of death. The highest rates of false-negative clinical diagnoses were for infectious diseases, with sensitivities under 50%. Hypertensive disorders (eclampsia) were the main false-positive diagnoses.36 All of the other studies of maternal mortality described above are based on diagnoses of maternal death from clinical records or verbal autopsy only. Although the study from Mozambique is a single-site tertiary-referral centre and the results cannot necessarily be extrapolated across sub-Saharan Africa, it does suggest that there might be substantial inaccuracies in the available data on causes of maternal mortality, particularly under-reporting of infection as a cause of death.36

Table 1
Summary of maternal morbidity data

Data on maternal morbidity in sub-Saharan Africa are very limited. Table 1 summarises those studies providing data on maternal morbidity from puerperal sepsis, or providing microbiological and histological data. These studies mainly comprise retrospective case reviews, facility based studies,27,28 or studies with substantial missing data.35 Some of the best evidence comes from the multinational, prospective, population-based study from west Africa, described above,30 which includes data on maternal morbidity and puerperal sepsis—19 545 women were actively followed up post partum.30 18 cases of puerperal sepsis were identified, representing a maternal morbidity ratio of 90 (50–140) per 100 000 live births. The six patients that died represented a case fatality ratio of 33%.

Estimates of the prevalence of maternal sepsis also come from intervention studies. Three clinical trials in sub-Saharan Africa intervened to reduce puerperal sepsis. A single facility-based trial in Malawi32 used manual antiseptic cleansing of the birth canal at vaginal examination, and wiping of the newborn at delivery. Post partum infection was diagnosed clinically after delivery, or if women re-presented (passive follow-up). Six (5·6%) of 107 women who delivered in the intervention period, compared with 17 (12·7%) of 134 women who delivered in the non-intervention period were diagnosed with puerperal sepsis.

The second study was a double-blind randomised controlled trial in two facilities in Durban, South Africa,31 among women infected with HIV in whom vaginal delivery was expected. A single dose of intravenous cefoxitin or placebo was given during birth, with follow up for signs of any infectious morbidity at 72 h, 1 week, and 2 weeks. Overall there was no significant difference in symptoms suggestive of puerperal sepsis, although cefoxitin significantly reduced endometritis.

The third study was community-based in ten surveillance sites across two rural districts of Mwanza, Tanzania,34 involving the provision of a clean delivery kit and maternal education on hygienic delivery. Allocation was dependent on maternal choice rather than randomisation; puerperal sepsis up to 5 days post partum was diagnosed in 1·1% (19) of women who used the kit and 3·6% (50) who did not.

It is clear that a single, reliable estimate of the incidence of puerperal sepsis in sub-Saharan Africa cannot be made. However, the available evidence suggests that infections around childbirth substantially contribute to maternal morbidity, are underestimated, are a leading cause of death in mothers in sub-Saharan Africa, and are more frequent in hospital-based deliveries than in the community. It is apparent that future studies should look at the morbidity and mortality from both puerperal sepsis and maternal sepsis not thought to be directly related to delivery, and should use adequate microbiological investigations.

Incidence of early onset neonatal sepsis

Neonatal sepsis, defined as sepsis within the first 28 days of life, is estimated to cause 26% of all neonatal deaths worldwide.6 Few studies in sub-Saharan Africa diff-erentiate between early and late onset neonatal sepsis and there are variations in the periods used to define early and late.37 Differentiation is important since early onset neonatal bacterial sepsis is more likely to reflect vertically acquired infection from the maternal genital tract. It therefore has a different aetiology to late onset neonatal sepsis, and potentially different means of prevention. Here, we define early onset neonatal bacterial sepsis as sepsis in neonates less than 7 days old and only include studies with microbiologically confirmed data.

Estimates of the incidence of neonatal sepsis are all from single-facility studies, and vary in their findings (table 2). A study from Malawi38 is the most specific, considering the incidence of early onset neonatal sepsis caused by S agalactiae alone, which was reported as 0·92 cases per 1000 live births.

Table 2
Summary of neonatal morbidity data

Regarding neonatal sepsis as a whole, 5·46 cases of neonatal bacteraemia per 1000 live births were recorded in Kilifi, Kenya,39 through blood-culture surveillance of all hospital admissions (both in-born and out-born neonates). In Nigeria, 6·5 cases of neonatal sepsis per 1000 live births occurring in a referral hospital were recorded.40 21 cases of neonatal sepsis per 1000 live births were reported from a referral hospital in Zimbabwe.41 Maternal deliveries in the Zimbabwean study were described as high risk and likely to result in a higher incidence of neonatal sepsis. Fewer cases (30 of 6630 live births) of neonatal sepsis were identified from community referrals (out-born neonates), but the authors do not calculate an incidence, due to the likelihood of missed cases.41

It is difficult to interpret these incidence data; the Zimbabwe41 and Nigeria40 single-facility studies considered all live births at that facility and their outcomes, using the number of births at the facility as the denominator to calculate incidence, but these cannot be extrapolated to the general population. The Malawian38 and Kenyan39 studies included both in-born and out-born neonates and estimated incidence based on catchment-population data. Their results are minimum estimates, since not all neonates with sepsis will have been referred, and cases of culture-negative sepsis would not be included. The denominators might also be reduced if birth records are incomplete.

Studies with a high proportion of in-born neonates are likely to have a higher proportion of early onset neonatal sepsis, 68% (110) of all neonatal sepsis cases in the Zimbabwe study were early onset.41 By contrast, community-based studies (including mainly out-born neonates), such as the multicentre WHO collaborative study, from The Gambia, Ethiopia, Papua New Guinea, and the Philippines,52 might be biased against recording early onset neonatal bacterial sepsis, because babies with severe early-onset infections might die before presentation. Only 30% (25) of neonatal sepsis cases in the WHO Young Infants study52 were early onset. Although the WHO study was not population-based, a simple calculation using data from Gambian sites can be made.42 There were 53 cases of young infant sepsis (infants younger than 90 days) from a catchment area of 12 000 births, which would give an incidence of 4·42 cases of young infant sepsis per 1000 live births (if the study is assumed to simultaneously cover both hospitals for a year, rather than each hospital studied consecutively for a year).

Intervention studies are also typically from single facilities, and therefore not necessarily representative of the population. Rates of admissions due to sepsis dropped immediately after birth canal cleansing was introduced in Malawi, and stayed substantially lower during the intervention period compared with the non-intervention months (7·8 vs 17·9 per 1000 live births).32 In South Africa, among mothers infected with HIV, a non-significant reduction in neonatal sepsis was also seen in the cefoxitin trial: neonatal sepsis was diagnosed in 1·3% of babies whose mothers received placebo and 0·7% of those whose mothers received cefoxitin.31 The community-based study in Mwanza34 considered neonatal sepsis only in terms of cord infection at 5 days. Five infants (0·3%) of women who used the kit and 48 infants of women who did not use the kit (3·9%) developed cord infection.

Estimates of incidence of early onset neonatal bacterial sepsis therefore vary widely, but the available data indicates a high burden of disease. Multisite population-based studies with uniform definitions would improve our understanding of early onset neonatal bacterial sepsis. This is important, since simple interventions reducing the incidence of early onset neonatal bacterial sepsis could be prioritised in health planning.


There are few microbiological data on puerperal sepsis in sub-Saharan Africa (table 1). A case–control study from Nairobi, Kenya,33 found a significant difference in the isolation of Neisseria gonorrhoeae or Chlamydia trachomatis from the endometrium and cervix of women with post-partum endometritis (35 cases) compared with those without (30 cases). Samples were taken at 6 days post partum for the isolation of these organisms and Mycoplasma hominis, Ureaplasma urealyticum (isolated equally from both cases and controls), and S agalactiae (not isolated in either group). A high prevalence (19; 28%) of N gonorrhoeae was also reported in cases of puerperal sepsis from a study of pelvic infections in Ethiopia.29 Another retrospective study from Nigeria,27 of microbiological isolates from the genital tract of patients with puerperal sepsis (taken for clinical purposes, sites not specified), identified S aureus (29; 20%) as the most common pathogen, followed by Escherichia coli (18; 12%) and Proteus sp (17; 12%). However, there was a low proportion of positive cultures (85 of 146), but there were no facilities for anaerobic culture and again, no growth of streptococcal species. Since these streptococcal species are fastidious organisms, isolation might have been limited by bacteriological facilities.

The aetiology of neonatal sepsis has been more frequently described (table 2), reflecting a recognised need for data to improve treatment guidelines.53 Before the WHO collaborative study (1990–93) in The Gambia, Ethiopia, the Philippines, and Papua New Guinea the main causative organisms described from non-industrialised countries were S aureus and Klebsiella sp,49,52 also reported more recently from Nigeria.48 The WHO study site in The Gambia used two facilities, including young infant admissions (younger than 91 days) to both a first-referral medical facility and tertiary-centre hospital. 38 infants without meningitis had positive blood cultures, specifically S aureus (17 cultures), Streptococcus pneumoniae (three), Salmonella spp (five), E coli (three), other enterobacteriaceae (four), Streptococcus pyogenes (group A streptococcus) (three), S agalactiae (group B streptococcus) (one), Moraxella spp (one), and group G streptococci (one).42 The Ethiopian site identified 41 positive cultures in young infants. S pneumoniae was common (ten), as were S pyogenes (nine) and Salmonella spp (five). However, S agalactiae was absent. Culture-confirmed cases of meningitis (15) were predominantly caused by S pneumoniae (seven).43

Recent research has challenged the findings of the WHO Young Infant study, regarding early onset neonatal bacterial sepsis. Bacteriological surveillance of all neonatal admissions in Kilifi, Kenya 1998–2002 identified S agalactiae as the most common Gram-positive organism and E coli as the most common Gram-negative organism isolated in neonates younger than 7 days.37 These findings are supported by data from Blantyre, Malawi,38,44 and from other single-facility studies in Kenya,45,47 Zimbabwe,41 and South Africa46 (table 2).

The disparity in S agalactiae is likely accounted for by study design. The WHO Young Infants study, like a Nigerian study,50 focused on outpatient referrals rather than in-born neonates. Severe, rapidly fatal, early onset neonatal bacterial sepsis was therefore probably under-represented compared with facility-based studies, because of the time needed to seek medical facilities. The newer findings are of particular note since S agalactiae infections have been substantially reduced with antibiotic-based prevention strategies in resource-rich countries. For example, chemoprophylaxis in the USA has reduced the incidence of early onset neonatal bacterial sepsis caused by S agalactiae from 1·7 per 1000 live births in 1993 to 0·6 per 1000 in 1998.11

Our knowledge of the aetiology of maternal sepsis is limited compared with our growing understanding of the aetiology of neonatal sepsis in resource-poor countries. The data highlight the need for systematic and representative sampling and quality-controlled culture facilities.

Risk factors for maternal sepsis

Risk factors for puerperal sepsis described in resource-rich countries include: home birth in unhygienic conditions, low socioeconomic status, poor nutrition, primiparity, anaemia, prolonged rupture of membranes (PROM), prolonged labour, multiple vaginal examinations (more than five), caesarean section, instrumental deliveries, retained products of conception, and post-partum haemorrhage.54 Widely accepted interventions to reduce the incidence of puerperal sepsis are the use of aseptic and sterile techniques (hand cleansing, and sterile drapes and instruments), and antibiotics targeted to deliveries by caesarean section, and those with PROM55 (which can be associated with S agalactiae carriage).56

Data on risk factors for puerperal sepsis in sub-Saharan Africa are limited and are likely to differ in relative importance to those in resource rich countries. Whilst high prevalence of HIV/AIDS, anaemia, malaria, and undernutrition is widely reported,57-59 their contribution to puerperal and maternal sepsis is largely unknown.

HIV/AIDS is, however, a well-recognised risk factor for maternal mortality and morbidity in sub-Saharan Africa. A population based, prospective study of 19 983 women in Rakai, Uganda,10 reported maternal mortality ratios of 1687 and 310 per 100 000 births in HIV-positive and HIV-negative mothers respectively. This finding is supported by the autopsy study in Mozambique, where HIV/AIDS-related conditions were the most common non-obstetric cause of death (12·9% due to opportunistic infection [bacterial, fungal, and viral]) and the confidential enquiry into maternal deaths in South Africa—HIV/AIDS-related conditions accounted for 20·1% of all maternal deaths.25 A high burden of morbidity post partum was described in mothers infected with HIV in Kenya.8 This prospective study followed up 535 women infected with HIV for a year post partum and reported 33 cases of pneumonia per 100 person years.

Operative or instrumental delivery is likely to be an association. In Nigeria, 14·7% of cases of puerperal sepsis followed caesarean section;27 however, without knowledge of the prevalence of this mode of delivery and indications for caesarean section, these results are difficult to interpret. In the prospective study on maternal morbidity from west Africa, although five of 18 cases (28%) of puerperal sepsis cases followed caesarean section, this represented a relatively low (1·5%) postoperative infection rate.30 The authors attribute this result to widespread and systematic antibiotic use in study areas.

Episiotomy is another potential risk factor. The cefoxitin trial in South Africa31 reported puerperal sepsis in 43 of 195 (22·1%) women with an episiotomy, compared to 33 of 229 (14·4%) without. Other risk factors similar to resource-rich settings were reported from this study, and PROM and increased number of vaginal examinations were significantly associated with puerperal sepsis.31 Other simple interventions, identified in the community study in Mwanza, Tanzania,34 significantly reducing the prevalence of puerperal sepsis, were bathing and shaving before delivery.

Genital-tract bacterial carriage might also predispose to (clinically defined) puerperal sepsis. A hospital based study in Zimbabwe reported increased prevalence of N gonorrhoeae, Bacteroides spp, Chlamydia spp, and Gardnerella vaginalis among mothers who developed puerperal sepsis,60 similar to isolates from cases of puerperal sepsis in the Kenyan study described33 and supported by a separate study in Zimbabwe associating maternal colonisation with N gonorrhoeae, S agalactiae, and Bacteroides spp with PROM.61

However, a multicentre study from Zimbabwe (Lusaka), Malawi (Blantyre and Lilongwe), and Tanzania (Dar es Salaam) aiming to reduce chorioamnionitis (on the basis of histological diagnosis) found that although oral antibiotics (metronidazole and erythromycin) at 24-weeks gestation reduced infection with Trichomonas vaginalis and bacterial vaginosis, there was no significant reduction in chorioamnionitis at delivery. Oral antibiotics (metronidazole and ampicillin) were also given at at birth.62

The relative importance of risk factors for maternal sepsis in sub-Saharan Africa depends both on the extent to which they predispose to infection, and their prevalence. More work is needed to establish the relative importance of risk factors in sub-Saharan Africa, since these risk factors might guide more effective antibiotic prophylaxis and offer new strategies for prevention. Research from a resource-poor setting outside of sub-Saharan Africa (Nepal) found a 40% reduction in maternal mortality with vitamin A or β-carotene maternal supplementation, although the extent to which this resulted from decreased maternal deaths from sepsis could not be reliably determined.63 However, this study does demonstrate that there might be simple prevention methods besides antisepsis and antibiotic measures that could be effective in reducing maternal sepsis and resultant maternal mortality.

Risk factors for early onset neonatal sepsis

Common risk factors for neonatal sepsis in sub-Saharan Africa have been identified as prematurity,45,46,64 PROM,41,45,64,65 maternal pyrexia,51,64,65 low birthweight,46,52 and difficulties at delivery (obstructed labour or birth asphyxia).47,51 These accord with risk factors identified in resource-rich settings, where they are used in a risk-based approach for intrapartum or early antibiotic treatment of neonates to prevent severe disease. However, by contrast with resource-rich countries, mothers with a history of a previous baby with S agalactiae infection or urinary tract infections are seldom identified in sub-Saharan Africa, probably because they were not investigated by bacterial culture.

Another approach in resource-rich countries to prevent early onset neonatal bacterial sepsis from S agalactiae (using intrapartum antibiotics) is through maternal genital tract screening.11 Whereas there have been no studies using screening to guide antibiotic prophylaxis in sub-Saharan Africa, several studies have looked at the prevalence of maternal S agalactiae genital tract carriage. Because early studies of early onset neonatal bacterial sepsis suggested a low incidence of S agalactiae neonatal sepsis, maternal carriage found in Nigeria, Ethiopia, and The Gambia were thought surprisingly high (13–22%).66-70 Low incidence of neonatal sepsis due to S agalactiae were attributed to less-invasive serotypes or neonatal protection from maternal antibodies. However, in view of more recent data on early onset neonatal bacterial sepsis aetiology, the results of these carriage studies are likely to be correct in their suggestion of S agalactiae prevalence, but the low actual numbers of mothers colonised and included in the studies would limit their power to detect early onset neonatal bacterial sepsis from S agalactiae.

Given the resources required for a screening-based approach to guide intrapartum antibiotic prophylaxis to prevent early onset neonatal bacterial sepsis, an approach based on risk factors is likely to be more applicable in sub-Saharan Africa. Some of the risk factors for early onset neonatal bacterial sepsis in sub-Saharan Africa are probably similar to those described in resource-rich settings, but have not been tested in the context of high rates of HIV, maternal undernutrition, fetal anaemia, and placental malaria. Although these risk factors have been linked to poor neonatal outcomes in sub-Saharan Africa,71 they have not been studied in relation to early onset neonatal bacterial sepsis in sub-Saharan Africa. This is of particular importance since the identification of additional risk factors for early onset neonatal bacterial sepsis could lead to effective simple prevention measures. Newer potential interventions such as maternal micronutrient supplementation might also contribute to preventing early onset neonatal bacterial sepsis. In a randomised trial of Tanzanian mothers infected with HIV (using multivitamins, vitamin A, or placebo arms to the trial), maternal micronutrient supplementation (but not vitamin A supplementation alone) decreased the risk of neonatal death, low birthweight, severe preterm birth, and small size for gestational age at birth; it also increased maternal CD3, CD4, and CD8 T-cell counts.72 Whether neonatal effects would be seen in mothers uninfected with HIV is unclear, and it is unknown whether early onset neonatal bacterial sepsis can be prevented. However, the Tanzanian study illustrates the need for epidemiological data and broad thinking in design of future prevention strategies to reduce early onset neonatal bacterial sepsis in sub-Saharan Africa.

Future strategies

There are many potential opportunities for reducing the burden of early onset neonatal bacterial and maternal sepsis. However, the benefit of any intervention (or package of interventions) can only be maximised if devised using high quality, reliable data on the burden and causes of morbidity. Observational data would ideally come from a large, population-based, multicentre study of maternal genital-tract carriage, with follow-up and microbiological investigation (based on clinical criteria) of neonatal and maternal sepsis and associated risk factors.

Recent consensus has highlighted the need for research priorities focused on health policy and systems research to reduce neonatal sepsis through assessment of the feasibility, effectiveness, and cost of promoting clean delivery practices in homes, primary-care facilities, and referral hospitals.73 These practices are supported by the experience of resource-rich countries and community-based studies in sub-Saharan Africa, such as the use of the clean delivery kit in Mwanza, Tanzania.34

However, there is also the potential for new interventions, which can be broadly divided into two groups: those aimed specifically at reducing infection in the peri-partum period using antisepsis measures and antibiotic prophylaxis (risk-based or from universal screening), and reducing susceptibility to infection by improving maternal health through nutritional supplementation, improved accessibility to antiretroviral therapy, investigation for and treatment of sexually transmitted infections, or, in the future, immunisation. The first approach targets facility-based deliveries, although the second would be mainly community-based and requires increased provision and uptake of antenatal care early in pregnancy.

Interventions should be targeted at the population they serve and the health-care facilities available. In the community, clean delivery practices should be prioritised. In referral centres with high-risk populations, new strategies should be developed, particularly the identification of risk factors for maternal and early onset neonatal bacterial sepsis in sub-Saharan Africa, which could be prevented through antibiotic prophylaxis.

Failure of progress towards MDGs four and five has made addressing these issues more urgent. It is likely that simple, straightforward strategies could prove effective in reducing sepsis. A purely descriptive study with reliable microbiological facilities would provide a sound foundation on which to base future intervention studies. However, a multi-armed, factorial trial with a combination of health interventions could result in the same background information and a more rapid advance in our understanding of the epidemiology and prevention of sepsis. Subsequent analyses would determine risk-groups in which interventions were most effective, ensuring optimum targeting of public-health interventions.


Despite a considerable burden of disease, there are strikingly few data on the precise incidence and aetiology of maternal or early onset neonatal bacterial sepsis in sub-Saharan Africa, largely because of a lack of reliable microbiological facilities. Simple intervention strategies are effective in other populations and evidence from a small number of intervention studies in sub-Saharan Africa supports the urgent need for further trials, so that public-health measures can be effectively directed and neonatal and maternal morbidity and mortality in sub-Saharan Africa is substantially reduced.

Search strategy and selection criteria

Data were identified using online searches of PubMed (January, 1966–March, 2009), the Cochrane Library and regional databases (African Index Medicus), accessed through WHO. Search terms included the following in various combinations: “maternal”, “neonatal”, “puerperal”, “sepsis”, “morbidity”, “mortality”, “carriage”, “colonisation”, “Africa”, “sub-Saharan”, “HIV”, “prevention”, and “intervention”. Reference lists of the identified articles were then searched to identify further relevant articles. Articles were selected on the basis of data originating from sub-Saharan Africa (unless in the context of interventions that could be applicable in this region) and their provision of estimates of incidence, aetiology, and risk factors for early onset neonatal bacterial sepsis or maternal sepsis. Data on incidence of early onset neonatal bacterial sepsis were based on papers providing microbiological diagnoses, but due to the paucity of published work on maternal sepsis, published data based on both clinical and microbiological diagnoses were included. No language or date restrictions were placed on these searches.


We would like to acknowledge and thank the support of the directors of the KEMRI/Wellcome Trust Programme (Kilifi) and KEMRI Centre for Geographic Medicine and Research (Coast). This paper is published with permission of the director of KEMRI. JAB and CRJCN are supported with Wellcome Trust Research Fellowships and ACS by Oxford University as a Wellcome Trust Visiting Fellow (UK).


Conflicts of interests

We declare that we have no conflicts of interest.


1. UN Development Programme MDG monitor: tracking the millennium development goals. [accessed Sept 1, 2008]. 2007.
2. WHO. UNICEF. UNFPA . Maternal mortality in 2005. World Health Organization; Geneva: [accessed Sept 1, 2008]. 2007. The World Bank.
3. UNICEF . Global progress in reducing child mortality is insufficient to reach MDG 4. United Nations Children’s Fund; New York: [accessed Sept 1, 2008]. 2008.
4. Countdown Coverage Writing Group and on behalf of the Countdown to 2015 Core Group Countdown to 2015 for maternal, newborn, and child survival: the 2008 report on tracking coverage of interventions. Lancet. 2008;371:1247–58. [PubMed]
5. Salama P, Lawn J, Bryce J, et al. Making the countdown count. Lancet. 2008;371:1219–21. [PubMed]
6. Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: when? where? why? Lancet. 2005;365:891–900. [PubMed]
7. Onah HE, Obi SN, Agbata TA, Oguanuo TC. Pregnancy outcome in HIV positive women in Enugu, Nigeria. J Obstet Gynaecol. 2007;27:271–74. [PubMed]
8. Walson JL, Brown ER, Otieno PA, et al. Morbidity among HIV-1 infected mothers in Kenya. J Acquir Immune Defic Syndr. 2007;46:208–15. [PMC free article] [PubMed]
9. Le Coeur S, Khlat M, Halembokaka G, et al. HIV and the magnitude of pregnancy-related mortality in Pointe Noire, Congo. AIDS. 2005;19:69–75. [PubMed]
10. Sewankambo NK, Gray RH, Ahmed S, et al. Mortality associated with HIV infection in rural Rakai district, Uganda. AIDS. 2000;14:2391–400. [PubMed]
11. Schrag SJ, Zywicki S, Farley MM, et al. Group B streptococcal disease in the era of intrapartum antibiotic prophylaxis. N Engl J Med. 2000;342:15–20. [PubMed]
12. Smaill F, Hofmeyr GJ. Antibiotic prophylaxis for caesarean section. Cochrane Database Syst Rev. 2002;3:CD000933. [PubMed]
13. Lawn JE, Rudan I, Rubens C. Four million newborn deaths: is the global research agenda evidence-based? Early Hum Dev. 2008;84:809–14. [PubMed]
14. Edwards M. Group B streptococcal conjugate vaccine: a timely concept for which the time has come. Hum Vaccin. 2008;4:444–48. [PubMed]
15. WHO . Mother–baby package: implementing safe motherhood in countries. World Health Organization; Geneva: [accessed Oct 18, 2008]. 1994.
16. Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet. 2006;367:1066–74. [PubMed]
17. Iloki LH, G’Bala Sapoulou MV, Kpekpede F, Ekoundzola JR. Maternal mortality in Brazzaville (1993–1994) J Gynecol Obstet Biol Reprod (Paris) 1997;26:163–68. in French. [PubMed]
18. Kodio B, de Bernis L, Ba M, Ronsmans C, Pison G, Etard JF. Levels and causes of maternal mortality in Senegal. Trop Med Int Health. 2002;7:499–505. [PubMed]
19. Macleod J, Rhode R. Retrospective follow up of maternal deaths and their associated risk factors in a rural district of Tanzania. Trop Med Int Health. 1998;3:130–37. [PubMed]
20. Moodley J. Saving mothers: report on confidential enquiries into maternal deaths in South Africa 1998. South African Ministry of Health; Pretoria: [accessed June 19, 2008]. 1998.
21. National Committee for Confidential Enquiries into Maternal Deaths . Second interim report on confidential enquiries into maternal deaths in South Africa: maternal deaths for 1999. South African Ministry of Health; Pretoria: [accessed June 19, 2008]. 1999.
22. Nsemukila BG, Phiri D, Diallo H, Banda SS, Benaya WK, Kitahara N. A study of factors associated with maternal mortality in Zambia, 1998. Zambian Ministry of Health; Lusaka: 1999.
23. Rutgers S. Two years maternal mortality in Matebeleland north province, Zimbabwe. Cent Afr J Med. 2001;47:39–43. [PubMed]
24. Bouvier-Colle MH, Ouedraogo C, Dumont A, et al. Maternal mortality in west Africa: rates, causes, and substandard care from a prospective survey. Acta Obstet Gynae Scand. 2001;80:113–19. [PubMed]
25. Ministry of Health Republic of South Africa . Saving mothers: report on confidential enquiries into maternal deaths in South Africa 2002–2004. South African Ministry of Health; Pretoria: [accessed June 16, 2008]. 2004.
26. Menéndez C, Romagosa C, Ismail MR, et al. An autopsy study of maternal mortality in Mozambique: the contribution of infectious diseases. PLoS Med. 2008;5:e44. [PubMed]
27. Dare FO, Bako AU, Ezechi OC. Puerperal sepsis: a preventable post-partum complication. Tropical Doct. 1998;28:92–95. [PubMed]
28. Lagro M, Liche A, Mumba T, Ntebeka R, van Roosmalen J. Postpartum health among rural Zambian women. Afr J Reprod Health. 2003;73:41–48. [PubMed]
29. Perine PL, Duncan ME, Krause DW, Awoke S. Pelvic inflammatory disease and puerperal sepsis in Ethiopia. Am J Obstet Gynaecol. 1980;138:969–73. [PubMed]
30. Prual A, Bouvier-Colle MH, de Bernis L, Bréart G. Severe maternal morbidity from direct obstetric causes in West Africa: incidence and case fatality rates. Bull World Health Organ. 2000;78:593–602. [PubMed]
31. Sebitloane H, Moodley J, Esterhuizen TM. Prophylactic antibiotics for the prevention of postpartum infectious morbidity in women infected with human immunodeficiency virus: a randomized controlled trial. Am J Obstet Gynecol. 2008 published online Nov 12, 2007. DOI:10.1016/j.ajog.2007.08.053. [PubMed]
32. Taha TE, Biggar RJ, Broadhead RL, et al. Effect of cleansing the birth canal with antiseptic solution on maternal and newborn morbidity and mortality in Malawi: clinical trial. BMJ. 1997;315:216–20. [PMC free article] [PubMed]
33. Temmerman M, Laga M, Ndinya-Achola JO, et al. Microbial aetiology and diagnostic criteria of postpartum endometritis in Nairobi, Kenya. Genitourin Med. 1988;64:172–75. [PMC free article] [PubMed]
34. Winani S, Wood S, Coffey P, Chirwa T, Mosha F, Changalucha J. Use of a clean delivery kit and factors associated with cord infection and puerperal sepsis in Mwanza, Tanzania. J Midwifery Womens Health. 2007;98:252–68. [PubMed]
35. Wollast E, Renard F, Vandenbussche P, Buekens P. Detecting maternal morbidity and mortality by traditional birth attendants in Burkina Faso. Health Policy Plan. 1993;8:161–68.
36. Ordi J, Ismail MR, Carrilho C, et al. Clinico-pathological discrepancies in the diagnosis of causes of maternal death in sub-Saharan Africa: retrospective analysis. PLoS Med. 2009;6:e1000036. [PMC free article] [PubMed]
37. Vergnano S, Sharland M, Kazembe P, Mwansambo C, Heath PT. Neonatal sepsis: an international perspective. Arch Dis Child Fetal Neonatal Ed. 2005;90:220–24. [PMC free article] [PubMed]
38. Gray KJ, Bennett SL, French N, Phiri AJ, Graham SM. Invasive group B streptococcal infections in infants, Malawi. Emerg Infect Dis. 2007;13:223–29. [PMC free article] [PubMed]
39. Berkley JA, Lowe BS, Mwangi I, et al. Bacteremia among children admitted to a rural hospital in Kenya. N Engl J Med. 2005;352:39–47. [PubMed]
40. Airede A. Neonatal septicaemia in an African city of high altitude. J Tropical Pediatr. 1992;38:189–91. [PubMed]
41. Nathoo KJ, Mason PR, Chimbira TH. Neonatal septicaemia in Harare hospital, aetiology and risk factors—the puerperal sepsis study group. Cent Africa J Med. 1990;36:150–56. [PubMed]
42. Mulholland EK, Ogunlesi OO, Adegbola RA, et al. Etiology of serious infections in young Gambian infants. Paediatr Infect Dis J. 1999;18:S35–41. [PubMed]
43. Muhe L, Tilahun M, Lulseged S, et al. Etiology of pneumonia, sepsis and meningitis in infants younger than three months of age in Ethiopia. Paediatr Infect Dis J. 1999;18:S56–61. [PubMed]
44. Milledge J, Calis J, Graham SM, et al. Aetiology of neonatal sepsis in Blantyre, Malawi: 1996–2001. Ann Trop Paediatr. 2005;25:101–10. [PubMed]
45. Laving AM, Musoke RN, Wasunna AO, Revathi G. Neonatal bacterial meningitis at the newborn unit of Kenyatta National Hospital. East Afr Med J. 2003;80:456–62. [PubMed]
46. Madhi SA, Radebe K, Crewe-Brown H, et al. High burden of invasive Streptococcus agalactiae in South African infants. Ann Trop Paediatr. 2003;23:15–23. [PubMed]
47. English M, Ngama M, Musumba C, et al. Causes and outcome of young infant admissions to a Kenyan District Hospital. Arch Dis Child. 2003;88:438–43. [PMC free article] [PubMed]
48. Udo JJ, Anah MU, Ochigbo SO, Etuk IS, Ekanem AD. Neonatal morbidity and mortality in Calabar, Nigeria: a hospital-based study. Niger J Clin Pract. 2008;11:285–89. [PubMed]
49. Ghiorghis B. Neonatal sepsis in Addis Ababa, Ethiopia: a review of 151 bacteraemic neonates. Ethiop Med J. 1997;35:169–76. [PubMed]
50. Adejuyigbe EA, Ako-Nai AK, Adisa B. Bacterial isolates in the sick young infant in Ile-Ife, Nigeria. J Trop Pediatr. 2004;6:323–27. [PubMed]
51. Ojukwu JU, Abonyi LE, Ugwu J, Orji IK. Neonatal septicaemia in high risk babies in south-eastern Nigeria. J Perinat Med. 2006;34:166–72. [PubMed]
52. The WHO Young Infants Study Group Bacterial etiology of serious infections in young infants in developing countries: results of a multicentre study. Paediatr Infect Dis J. 1999;18:S17–22. [PubMed]
53. The WHO Young Infant Study Group Serious infections in young infants in developing countries: rationale for a multicenter study. Pediatr Infect Dis J. 1999;18:S4–7. [PubMed]
54. Maharaj D. Puerperal pyrexia: a review, part I. Obstet Gynaecol Surv. 2007;62:393–99. [PubMed]
55. Maharaj D. Puerperal pyrexia: a review, part II. Obstet Gynaecol Surv. 2007;62:400–06. [PubMed]
56. Regan JA, Chao S, James LS. Premature rupture of membranes, preterm delivery, and group B streptococcal colonization of mothers. Am J Obstet Gynecol. 1981;141:184–86. [PubMed]
57. Lartey A. Maternal and child nutrition in sub-Saharan Africa: challenges and interventions. Proc Nutr Soc. 2008;67:105–08. [PubMed]
58. McIntyre J. Mothers infected with HIV. Br Med Bull. 2003;67:127–35. [PubMed]
59. Weiner R, Ronsmans C, Dorman E, Jilo H, Muhoro A, Shulman C. Labour complications remain the most important risk factors for perinatal mortality in rural Kenya. Bull World Health Organ. 2003;81:561–66. [PubMed]
60. Mason PR, Katzenstein DA, Chimbura TH, Mtimavlave L. Microbial flora of lower genital tract of women in labour at Harare Maternity Hospital—the puerperal sepsis study group. Cent Afr J Med. 1989;35:337–44. [PubMed]
61. Mason P, Katzenstein DA, Chimbira THK, Mtimavalye L. Vaginal flora of women admitted to hospital with signs of sepsis following normal delivery, cesarean section or abortion—the puerperal sepsis study group. Cent Afr J Med. 1989;35:344–51. [PubMed]
62. Goldenberg RL, Mwatha A, Read JS, et al. The HPTN 024 Study: the efficacy of antibiotics to prevent chorioamnionitis and preterm birth. Am J Obstet Gynecol. 2006;194:650–61. [PubMed]
63. West K, Katz J, Khatry SK, et al. Double blind, cluster randomised trial of low dose supplementation with vitamin A or β-carotene on mortality related to pregnancy in Nepal—the NNIPS-2 study group. BMJ. 1999;318:570–75. [PMC free article] [PubMed]
64. Bomela HN, Ballot DE, Cooper PA. Is prophylaxis of early onset group B streptococcal disease appropriate for South Africa? S Afr Med J. 2001;91:858–60. [PubMed]
65. Ben Hamida Nouaili E, Harouni M, Chaouachi S, Sfar R, Marrakchi Z. Early onset neonatal bacterial infections: a retrospective series of 144 cases. Tunis Med. 2008;86:136–39. [PubMed]
66. Dawodu AH, Damole IO, Onile BA. Epidemiology of group B streptococcal carriage among pregnant women and their neonates: an African experience. Trop Geogr Med. 1983;35:145–50. [PubMed]
67. Schmidt J, Halle E, Halle H, Mohammed T, Gunther E. Colonisation of pregnant women and their newborn infants with group B streptococci in the Gondar College of Medical Sciences. Ethiop Med J. 1989;27:115–19. [PubMed]
68. Onile BA. Group B streptococcal carriage in Nigeria. Trans R Soc Trop Med Hyg. 1980;74:367–70. [PubMed]
69. Suara RO, Adegbola RA, Baker CJ, Secka O, Mulholland EK, Greenwood BM. Carriage of group B streptococci in pregnant mothers and their infants. J Infect Dis. 1994;70:1316–19. [PubMed]
70. Uhiara J. Group B streptococcal carriage among parturients and their neonates in Zaria, Nigeria. Afr J Med Med Sci. 1993;22:79–83. [PubMed]
71. Van Eijk AM, Ayisi JG, Ter Kuile FO, et al. HIV, malaria and infant anaemia as risk factors for postneonatal infant mortality among HIV-seropositive women in Kisumu, Kenya. J Infect Dis. 2007;196:30–37. [PubMed]
72. Fawzi WW, Msamanga GI, Spiegelman D, et al. Randomised trial of effects of vitamin supplements on pregnancy outcomes and T cell counts in HIV-1-infected women in Tanzania. Lancet. 1998;351:1477–82. [PubMed]
73. Bahl R, Martines J, Ali N, et al. Research priorities to reduce global mortality from newborn infections by 2015. Pediatr Infect Dis J. 2009;28(suppl 1):S43–48. [PubMed]