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Factors Influencing Prevalence of Surgical Site Infections among Mothers Undergoing Ceaserean Section in Iganga Hospital, Uganda

Isakwa Ibrahim                                       

Faculty of Clinical Medicine and Dentistry Kampala International University Western Campus Uganda.                                                         

ABSTRACT

Caesarean Section as a mode of delivery is the most commonly done surgical procedure in maternity departments all over the world. Surgical site infection complicates about one-third to two-thirds of caesarean sections in low-income countries which is about 9 times higher compared with the high-resource countries. Surgical Site Infection is associated with increased maternal morbidity, prolonged hospital stay and increased medical costs. The development of post-caesarean surgical site infection is hung on a complex interplay of many factors not limited to wound class, immune status, maternal age, hypertensive disorders, ASA classification, number of vaginal examinations, the virulence of the microorganisms, maternal weight, surgical techniques and premature rupture of membrane. The study employed a descriptive cross-sectional and quantitative approach to study the factors influencing the prevalence of surgical site infections among mothers undergoing caesarean section in Iganga Hospital. A sample size of 288 participants were enrolled using a random sampling technique and close-ended questionnaires were employed to obtain the data from participants. Data analysis was done using SPSS version 20 and statistical significance      was set at a P-value less than 0.05 at 95% confidence interval. A total of 288 post-caesarean mothers were studied from October – November 2021 in Iganga Hospital. The majority of the participants were married 255(88.8%) and had a secondary level         of education 142(49.3%). The mean age of the participants were 25.6 years with 21 as the modal age. The prevalence of surgical site infection among post-caesarean mothers at Iganga Hospital was 20.5% (59 out of 288) and the factors which were statistically influencing the SSI included early rupture of membranes of more than 18 hours (aOR 23.715 95% C.I 5.976-94.117, P 0000) and postoperative haemoglobin (aOR 15.109 95% C.I 3.494-65.333, P 0.000) There’s a high burden of SSI among post-caesarean mothers in Iganga Hospital. Early rupture of membranes more than 18 hours and post-operative haemoglobin less than 11g/dl are key  contributory factors. Aggressive prophylactic and post-operative antibiotic therapy should be considered in mothers with early rupture of membranes and post-operative anaemia.

Keywords: Caesarean Section, Maternal morbidity, Surgical Site Infection, Post-caesarean mothers, Vagina examination.

INTRODUCTION

Cesarean Section (CS) is one of the most commonly performed surgical procedures in the obstetrical gynaecological department. Surgical site infection (SSI) after cesarean section (CS) increases maternal morbidity, hospital stay and medical cost [1], [2]. Although SSIs are among the most preventable HAIs, they still represent a significant burden in terms of patient morbidity and mortality and additional costs to health systems and service payers worldwide [3]. Motherhood is a life-changing event. Successful physiological, as well as psychological, adjustment will be compromised when the arrival of the baby is coupled with recovery from major abdominal surgery and coping with the pain and discomfort of an abdominal wound. Difficulties are compounded when SSI develops, especially in today’s climate of early hospital discharge, which leaves women to cope at home, sometimes with little practical and emotional support [4]. According to the Centers for Disease Control and Prevention (CDC), surgical site infection (SSI) is defined as an infection which occurs within 30 days after a surgical procedure involving the skin, subcutaneous tissue, soft tissue or any other part of the anatomy. In general, in developing countries, the burden of health-care-associated infection including SSIs is assumed to be higher though the problem remains underestimated or even unknown [5], [1].

In a cross-sectional study of mothers who delivered by Cesarean at Mbarara Regional Referral Hospital 2020, the single most important risk factor for post-partum maternal infection is Cesarean section (C/S) with a 5-20-fold greater risk for infection compared to a vaginal delivery. Post-Cesarean wound infection is diagnosed in 2.5 to 16 per cent of patients [6]. The development of post-CS infection depends on a complex interplay of many factors including wound class, immune status, maternal age, hypertensive disorders, ASA classification, number of vaginal examinations, the virulence of the microorganisms, maternal weight, surgical techniques and premature rupture of membrane. [7] According to a study done in China, 3.34% of cesarean deliveries (CDs) were complicated by SSI in contrast, SSI complicated 12.6% and 24.3% of CDs in (Pakistan) respectively. [4] A prevalence rate of 6.2%.SSI following CDs was reported in a study done in Ankara (Turkey) and a lower rate of SSI (3.7%) was reported in a study done in Israel. [8] A study at Teaching Hospital in Rwanda revealed that 4.9% of CDs were complicated by SSI. [9] However, SSI following CDs was reported on almost half (48.2%) of CDs at Tanzanian Tertiary Hospital. [7] In the Ethiopian context, the prevalence of SSI at Hawassa and Teaching and Referral Hospital was 11%. Meanwhile, 9.4% of CDs were complicated by SSI at Assela Teaching and Referral Hospital. Similarly, a study done at Lemlem Karl General Hospital (Tigray region) revealed 6.8% of CDs had developed SSI. [10], [1]. Pre-operative conditions such as prolonged labour, prolonged rupture of membrane (PROM), more than 5 digital vaginal Examination, chorioamnionitis, American Society of Anesthesiologist (ASA) health status classification ≥3, fewer years of education, higher prior births, prior diagnosis of hypertension and Diabetes Mellitus (DM) were identified as significant factors for SSI following CDs [9]. Similarly, intraoperative conditions like prolonged duration of surgery, wound contamination class III, vertical skin incision and interrupted skin suturing were associated factors for developing SSI. [10]. In addition, CDs for emergency conditions like non-reassuring fetal heart rate pattern (NRFHRP) were also a significantly associated factor for developing SSI. In addition, Postoperative anaemia was also found to be a post-operative factor associated with SSI. [9] Frequent digital pelvic examination is one of the established preoperative factors that increase the risk of post-cesarean wound infection. Repeated vaginal examinations can introduce endogenous vaginal flora capable of causing SSI to the upper genital tract [1]. Despite every effort to maintain asepsis, almost all surgical sites are contaminated with bacteria, but the degree of contamination and the risk of subsequent infection vary among patients.

DISCUSSIONS

The prevalence of surgical site infection among pregnant mothers who underwent caesarean section at Iganga Hospital was 20.5% (59 out of 288). This is higher than the 15.6% observed in the Cochrane review in sub-Saharan Africa [18] and in Bwindi community hospital of 3.5% [19]. The wound sepsis rate was 16.8% in Hoima Regional referral hospital [20]. However, the prevalence was lower than that observed in New Delhi of 24.2% of mothers doing lower segment caesarean section [21]. This could be because this was a cross-sectional study and might have missed out on mothers who developed SSI post-discharge. The factors statistically associated with post-caesarean surgical site infection included early rupture of membranes (aOR 23.715(5.976-94.117) and post-operative haemoglobin (aOR 15.109 (3.49465.333) Early rupture of membranes of more than 18 hours increased the risk of surgical site infection by 23.715 times and it was statistically significant with a p-value of 0.000. this is attributable to the fact that a break in the sterility of the uterine cavity gives an opportunity for entry of ascending infections and thus increases the risk for SSI. The study findings agree with case study findings in Sierra Leon where early rupture of membranes increased the risk of SSI by 50 % [22]. Furthermore, a meta-analysis in Africa found a 6 times increased risk for SSI [23] While in Ethiopia it increased by 2.27 [24].

Additionally, having a post-operative Hemoglobin of less than 11.0g/dl (anaemic) was associated with 15.109 increased odds of surgical site infection with a significance of 0.0000 P-value at a 95% confidence interval. This is attributable to the hypo perfusion of the wound secondary to the low haemoglobin concentration thus limiting oxygen supply to the wound thus increasing the risk of wound infection by a compromised macrophage activity and wound healing process [25]. The study finding was in agreement with [25] who found 4.51 increased odds for SSI in mothers with post-operative Hb <11g/dl in Ethiopia while in Goyeneche Hospital of Arequipa, moderate and mild anaemia increased the odds by 2.71 and 2.80 respectively [26]-[29]. In Mwanza, Tanzania severe anaemia increased the risk of SSI by 3.8 [7].

CONCLUSIONS

There was a high prevalence of surgical site infection among post-caesarean mothers at Iganga Hospital. There was no demographic factor that was influencing surgical site infection among mothers delivered by caesarean section at Iganga Hospital. Early rupture of membranes for more than 18 hours was 23.7 times associated with increased occurrence of surgical site infection among mothers delivered by caesarean section in Iganga Hospital. Post-operative haemoglobin below 11g/dl increases the odds of surgical site infection by 15 times among mothers delivered by caesarean section in Iganga Hospital.

Recommendations

Aggressive prophylactic and post-operative antibiotics therapy should be considered in mothers with early rupture of membranes and post-operative anaemia.

REFERENCES

  1. Wodajo, S., Belayneh, M., & Gebremedhin, S. (2017). Magnitude and Factors Associated with Post-Cesarean Surgical Site Infection at Hawassa University Teaching and Referral Hospital, Southern Ethiopia: A Cross-Magnitude and Factors Associated with Post-Cesarean Surgical Site Infection at Hawassa University Teaching and Referral Hospital, Southern Ethiopia: A Cross-sectional Study. August 2018. https://doi.org/10.4314/ejhs.v27i3.10.
  2. Doshi, C., Mohite, S., Khatavkar, S., & Vaghani, S. (2014). Anesthetic management for elective cesarean section in a case of acromegaly with diabetes mellitus. Saudi Journal of Anaesthesia, 8(1), 139.
  3. Global guidelines for the prevention of surgical site (n.d.). Devjani, D., Sonal, S., Geeta Mehta, Yadav, R., & Dutta, R. (2013). Risk Factor Analysis and Microbial Etiology of Surgical Site Infections Following Lower Segment Caesarean Section.International Journal of Antibiotics, 2013, 1–6.
  4. Shrestha, S., Shrestha, R., Shrestha, B., & Dongol, A. (2014). Incidence and Risk Factors of Surgical Site Infection Following Cesarean Section at Dhulikhel 12(2), 113–116.
  5. Adane, , Mulu, A., Seyoum, G., Gebrie, A., & Lake, A. (2019). Prevalence and root causes of surgical site infection among women undergoing caesarean section in Ethiopia: a systematic review and meta-analysis. 1–10.
  6. Isanga, J., Emmanuel, B., Musa, K., Julius, M., Tibaijuka, L., Ronald, M., & Ngonzi, J. (2020). The Prevalence, Risk Factors, and Bacterial Profile of Cesarean Surgical Site Infections at a University Teaching Hospital in South Western Uganda. 5(1), 5–10.
  7. Mpogoro, J., Mshana, S. E., Mirambo, M. M., Kidenya, B. R., & Gumodoka, B. (2014).Incidence and predictors of surgical site infections following caesarean sections at Bugando Medical Centre, Mwanza, Tanzania. Antimicrobial Resistance and Infection Control, 3(25), 1–10.
  8. Gedefaw, , Asires, A., Shiferaw, S., & Addisu, D. (2018). Factors associated with surgical site infection among women undergoing obstetrics surgery at Felegehiwot Referral Hospital, Bahir Dar, Northwest Ethiopia: a retrospective cross-sectional study. 1–9.
  9. Molla, M., Temesgen, K., Seyoum, T., & Melkamu, M. (2019). Surgical site infection and associated factors among women who underwent cesarean delivery in Debretabor General Hospital, Northwest Ethiopia: a hospital-based cross-sectional 0, 1–10.
  10. Lijaemiro, H., Lemlem, S. B., & Deressa, J. T. (2020). Incidence of Surgical Site Infection and Factors Associated among Cesarean Deliveries in Selected Government Hospitals in Addis Ababa, Ethiopia, 2019.
  11. World Health Organization. Global guidelines for the prevention of surgical site infection. 2nd ed. Geneva: World Health Organization; 2018.
  12. Ministry of Health (2014) Statistical Year Book 1435H.http://www.moh.gov.sa/en/Ministry/Statistics/Book/Pages/default.aspx
  13. Greco, D., & Magombe, I. (2011). Hospital acquired infections in a large north Ugandan hospital. Journal of preventive medicine and hygiene, 52(2), 55–58.
  14. Ugwu, C. N., & Eze, V. H. U. (2023). Qualitative Research. IDOSR of Computer and Applied Science, 8(1), 20–35.
  15. Rutebemberwa, E., Lubega, M., Katureebe, S. K., Oundo, A., Kiweewa, F., & Mukanga, D. (2013). Use of traditional medicine for the treatment of diabetes in Eastern Uganda: a qualitative exploration of reasons for choice. BMC international health and human rights, 13, 1. https://doi.org/10.1186/1472-698X-13-1
  16. Creswell, J. W. (2012). Qualitative inquiry & research design: Choosing among five approaches (4th ed.). Thousand Oaks, CA: Sage.
  17. Ugwu Chinyere Nneoma, Eze Val Hyginus Udoka, Ugwu Jovita Nnenna, Ogenyi Fabian Chukwudi and Ugwu Okechukwu Paul-Chima (2023). Ethical Publication Issues in the Collection and Analysis of Research Data. NEWPORT INTERNATIONAL JOURNAL OF SCIENTIFIC AND EXPERIMENTAL SCIENCES (NIJSES) 3(2): 132-140.
  18. Sway, , Nthumba, P., Solomkin, J., Tarchini, G., Gibbs, R., & Ren, Y. (2019). The burden of surgical site infection following cesarean section in sub-Saharan Africa: a narrative review. International Journal of Women’s Health, 309–318.
  19. Kurigamba, G. K., Namara, D., Nanyanga, I., Nahabwe, H., & Mutahunga, B. R. (2018). POST CESAREAN WOUND SEPSIS: Recognizable Risks and Causes at a Rural Ugandan International Journal of Women’s Health Care, 3(2), 6–9.
  20. Muhumuza, I., Lavingia, A. Z., Tayebwa, B., Ahmed, A. A., Koriow, F. M., Tetty, V. O., Nzabandora, E., Almenares, U., Fonseca, I. B., Kyobutungi, V., Turyagumanawe, J., Atuheire, C., & Ssebuwufu, R. (2020). Post Caesarean Wound sepsis and associated factors among patients attending a rural regional referral hospital in Western Uganda: A cross-sectional Research Square, 1–34.
  21. Devjani De, Sonal Saxena, Geeta Mehta, Reena Yadav, Renu Dutta, “Risk Factor Analysis and Microbial Etiology of Surgical Site Infections following Lower Segment Caesarean Section”, International Journal of Antibiotics, vol. 2013, Article ID 283025, 6 pages, 2013. https://doi.org/10.1155/2013/283025.
  22. Gennaro, F. Di, Marotta, C., Pisani, L., Veronese, N., Pisani, V., Oliva, F., Lippolis, V., Pellizer, , Pizzol, D., Tognon, F., Bavaro, D. F., Putoto, G., & Gennaro, F. Di. (2020). Maternal caesarean section infection (MACSI) in Sierra Leone: a case–control study. Epidemiology and Infection, 148(e40), 1–6.
  23. Mekonnen, A. G., & Mittiku, Y. M. (2021). Surgical site infection and its association with rupture of membrane following cesarean section in Africa: a systematic review and meta-analysis of Maternal Health, Neonatology, and Perinatology, 7(2), 1–9.
  24. Alemye, T., Id, L. O., Id, G. F., Merid, M., & Id, M. (2021). Post cesarean section surgical site infection and associated factors among women who delivered in public hospitals in Harar city, Eastern Ethiopia: A hospital-based analytic cross-sectional PloS One, 16(6), 1–12. https://doi.org/10.1371/journal.pone.0253194.
  25. Ayala, D., Id, T. T., Markos, J., & Yilma, M. T. (2021). Magnitude and factors associated with surgical site infection among mothers who underwent cesarean delivery in Nekemte town public hospitals, western Ethiopia. PloS One, 16(4), 1–12. https://doi.org/10.1371/journal.pone.0250736.
  26. Kelly, V. Y., Yerba, K., Failoc-rojas, V., Zeña-ñañez, S., & Valladares-, M. (2020). Factors Associated with Surgical Site Infection in Post-Cesarean Section: A Case-Control Study in a Peruvian Hospital. Ethiop J Health Sci, 30(1), 10–15.
  27. Winnie, O. A. (2023). Post Cesarean Care for Mothers Attending Arua Regional Referral Hospital Drivers and Challenges. Newport International Journal of Biological and Applied Sciences. 3(2), 185-200.
  28. Kojoki, V. (2023). Factors Influencing Success of Vaginal Delivery after Caesarean Section among Women with One Previous Scar at Hoima Regional Referral Hospital, Western Uganda. Eurasian Experiment Journal of Scientific and Applied Research (EEJSAR). 4(1), 106-115.
  29. Mercy, M. M. (2023). Knowledge and Practices on Infection Control among Health Workers in Jinja Regional Referral Hospital. Newport International Journal of Scientific and Experimental Sciences. 3(2), 141-148

CITE AS: Isakwa Ibrahim (2023). Factors Influencing Prevalence of Surgical Site Infections among Mothers Undergoing Ceaserean Section in Iganga Hospital, Uganda. IDOSR JOURNAL OF APPLIED SCIENCES 8(3) 1-14. https://doi.org/10.59298/IDOSR/2023/10.2.1400

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