The Effect of Surveillance and Appreciative Inquiry on Puerperal Infections: A Longitudinal Cohort Study in India

Abstract

ObjectiveTo evaluate the effects of an intervention comprising surveillance and an organisational change called Appreciative Inquiry on puerperal infections in hospitals in Gujarat state, India.MethodsThis longitudinal cohort study with a control group was conducted over 16 months between 2010 and 2012. Women who delivered in six hospitals were followed-up. After a five month pre-intervention period, the intervention was introduced in three hospitals. Monthly incidence of puerperal infection was recorded throughout the study in all six hospitals. A chi-square test and logistic regression were used to examine for associations, trends and interactions between the intervention and control groups.FindingsOf the 8,124 women followed up, puerperal infections were reported in 319 women (3.9%) over the course of the study. Puerperal sepsis/genital tract infections and urinary tract infections were the two most common puerperal infections. At the end of the study, infection incidence in the control group halved from 7.4% to 3.5%. Levels in the intervention group reduced proportionately even more, from 4.3% to 1.7%. A chi-square test for trend confirmed the reduction of infection in the intervention and control groups (p<0.0001) but the trends were not statistically different from one another. There was an overall reduction of infection by month (OR = 0.94 95% CI 0.91–0.97). Risk factors like delivery type, complications or delivery attendant showed no association with infection.ConclusionInterruption of resource flows in the health system occurred during the intervention phase, which may have affected the findings. The incidence of infection fell in both control and intervention groups during the course of the study. It is not clear if appreciative inquiry contributed to the reductions observed. A number of practical and methodological limitations were faced.Trial RegistrationControlled-Trials.com ISRCTN03513186

IndOSS-Assam: investigating the feasibility of introducing a simple maternal morbidity surveillance and research system in Assam, India

“…26 While puerperal sepsis is a known cause of maternal mortality in India, we found only one study that provided estimated incidence of puerperal sepsis in six hospitals in the state of Gujarat. 27 The study reported an incidence of 4%, which is higher than the 0.2% estimated through IndOSS-Assam. 27 A study that reviewed the records of all deliveries in a tertiary hospital in Chandigarh over a period of 15 years (January 1988 to December 2002) found 315 cases of septic abortion among 46 417 deliveries, giving an incidence of 0.7%, which is comparable to that estimated through IndOSS-Assam in the two pilot hospitals, although the case-fatality rate in the Assam hospitals (31%) was higher than that estimated in the Chandigarh hospital (25%).…”

“… 27 The study reported an incidence of 4%, which is higher than the 0.2% estimated through IndOSS-Assam. 27 A study that reviewed the records of all deliveries in a tertiary hospital in Chandigarh over a period of 15 years (January 1988 to December 2002) found 315 cases of septic abortion among 46 417 deliveries, giving an incidence of 0.7%, which is comparable to that estimated through IndOSS-Assam in the two pilot hospitals, although the case-fatality rate in the Assam hospitals (31%) was higher than that estimated in the Chandigarh hospital (25%). 28 A hospital in central India estimated an incidence of 0.06% for uterine rupture over a period of 12 years (1989–2000), with a case-fatality rate of 6%.…”

Using ‘appreciative inquiry’ in India to improve infection control practices in maternity care: a qualitative study

“…Results are from the qualitative study and quantitative findings are reported in another paper ( 19 ). Findings are presented, firstly, as opinions and descriptions of the general situation which included the challenges faced, and secondly, as perceptions of changes which might have occurred as a result of AI.…”

“…This qualitative study comprised one component of a wider research project. The second quantitative component monitored post-partum infections in 8,124 women, reported in another paper ( 19 ). The selection of six hospitals was based on the number of deliveries required for the quantitative study including sufficient case load (numbers of deliveries and capacity to deal routinely with obstetric complications), mix of government and private non-profit facilities, willingness to participate, and also other practical considerations like feasibility for follow-up.…”

Childbed fever: history repeats itself?

“…Primary prevention has become even more important with the emergence of antibiotic resistance, which both limits the effectiveness of antibiotics and necessitates the restriction of their availability. Such restriction in relation to childbirth is acknowledged across the globe, but challenged by recent work in India where almost two‐thirds of deliveries in institutions received antibiotics . Antimicrobial treatment will, of course, still be needed for sepsis cases, but effective prevention will reduce the overall need.…”