IMPROVING THE PREVENTION OF INFECTION FOLLOWING CAESAREAN SECTION IN MALAWI

Introduction: Global rates of maternal morbidity and mortality remain unacceptably high, and infection is a leading cause of death. Caesarean section (CS) is an important risk factor for maternal infection, particularly through the development of deep surgical site infection (SSI). This is a preventable problem, disproportionately affecting women in low-resource settings. Evidence-based strategies to prevent post-CS infection are recommended in international guidance, though feasibility of their implementation in low-resource settings remains to be demonstrated. Methods: The aim of this research was to improve the prevention of SSI following CS in low-resource settings. This was achieved by conducting three separate studies. 1) The Maternal Mortality Study investigated the causes of maternal death in Malawi and their associated factors, with a focus on CS and infection-related deaths. This was a secondary analysis of routinely collected data using descriptive statistics and logistic regression. 2) The IP@CS (Infection Prevention @ Caesarean Section) baseline study examined the context for infection prevention (IP) in low-resource maternity facilities in Malawi using mixed methods. Quantitative methods were used to analyse resource availability for IP and adherence to recommended IP practices. Qualitative methods were used to observe IP practices in context (ethnographic participant observation), and to explore findings (in-depth interviews). 3) The IP@CS interventionfeasibility study implemented a complex intervention to improve IP using a recognised framework for intervention selection and design, informed by behaviour change theory. Proctor’s Framework for Implementation Research was used in evaluation. Results: 1) Analysis of maternal deaths in Malawi determined that the leading causes of death were infection (24.8%), postpartum haemorrhage (20.4%) and eclampsia (13.3%). Over half of women who died postnatally had undergone a CS (50.5%). 2) Though adherence to antibiotic prophylaxis and skin preparation with antiseptic for women undergoing CS was good, baseline adherence to general recommendations for IP practice was poor. Barriers and facilitators to both recommended IP practice and a proposed intervention to improve IP at the time of CS were determined. Findings informed the selection, development and implementation of the complex intervention. 3) Vaginal preparation with antiseptic prior to skin incision at CS was successfully implemented; 94.8% of women undergoing caesarean section receiving the intervention. Two out of three facilities demonstrated good adoption, penetration and sustainability, although some 21 challenges were experienced at the third facility. Overall, the intervention was found to be acceptable, appropriate and feasible in this setting. Discussion and Conclusion: This research demonstrates the feasibility of implementing vaginal preparation with antiseptic at CS for the prevention of SSI. With thorough evaluation of the factors positively and negatively influencing adoption, integration and sustainability, it supports the recommendation of this practice in other low-resource settings, as well as providing lessons for how this could be achieved. Furthermore, the analysis of maternal deaths led to the production of a national report with policy recommendations for the reduction of avoidable maternal deaths in Malawi.