Anticipated impact on the organization of care and resources
The evidence-based recommendations for the prevention and treatment of maternal infections in this guideline can be achieved with the use of relatively inexpensive practices and drugs. The GDG noted that the following issues should be considered to increase the impact and facilitate implementation of the recommendations made in this guideline:
Ensure adequate WASH (water availability and quality, presence of sanitation facilities and availability of soap and water for hand washing) services at the facility level as an essential component of provision of care and infection prevention.
Establish effective hygiene and infection prevention and control measures, based on current best practice at the facility level, including housekeeping and waste disposal.
Health systems should ensure reliable supply systems and sustain availability and equitable access to antiseptics and antibiotics for use in obstetrics listed in the WHO Model List of Essential Medicines.
Ensure high quality standards for the sterilization and storage of instruments and supplies used for labour- and childbirth-related procedures (e.g. episiotomy, vacuum- and forceps-assisted vaginal birth and caesarean section).
Establish protocols to maintain fundamental surgical aseptic techniques (e.g. appropriate skin preparation, sterile drapes and instruments, gentle tissue handling, and haemostasis) when performing a caesarean section to reduce postoperative complications, including infection.
Provide clear guidance for timely transfer of women to an obstetric-led facility for management of maternal and newborn peripartum infections.
Provide clear guidance for timely transfer of women to specialized services (e.g. intensive care unit) for the management of maternal severe sepsis and septic shock and ensure availability of a protocol on resuscitation, antimicrobial therapy and subsequent supportive therapies.
Provide standard postpartum care and follow-up, both at the facility and in the community, as required by the context, to ensure early identification and treatment of puerperal infections.
Monitoring and evaluating the guideline implementation
The implementation and impact of the recommendations in this guideline should be monitored at the health-service, regional and country levels based on clearly defined criteria and indicators that are associated with locally agreed targets. The recommended set of outcomes, measures and indicators can be adapted by regional and country levels to assess the impact of implementing and adherence to the guideline recommendations.
In collaboration with the WHO RHR and MCA departments' monitoring and evaluation team, data on country- and regional-level implementation of the recommendations will be collected and evaluated in the short to medium term to assess its impact on the national policy of individual WHO Member States. Information on recommended indicators can also be obtained at the local level by interrupted time series or clinical audits. In this context, the GDG suggests the following indicators to be considered:
Proportion of women undergoing caesarean section who receive antibiotic prophylaxis, calculated as the number of women who receive antibiotic prophylaxis for caesarean section divided by the total number of women undergoing caesarean section.
Proportion of women with PPROM who receive antibiotic prophylaxis, calculated as the number of women with PPROM who receive antibiotic prophylaxis divided by the total number of women with PPROM.
Incidence of surgical wound infection among women undergoing caesarean section, calculated as the number of women with surgical wound infection after caesarean section divided by the total number of women undergoing caesarean section.
The first two indicators provide an assessment of the use of evidence-based practices among women considered at higher risk of infection around childbirth, while the last indicator provides information on the efficacy of the intervention. The use of other locally developed indicators (e.g. use of practices that are not recommended, such as routine use of antibiotics for episiotomy and uncomplicated vaginal birth) may be necessary to better assess the quality of care related to prevention and treatment of peripartum infection morbidity.
