Table 3 Suggested actions for improved prevention and management of maternal infections and sepsis identified from reviews

1. Prior to arrival to a level 3 facility

1.1. Need for improved pre-conception care

• Improve family planning counselling and contraceptive services during antenatal and postpartum care to promote birth spacing and planning of pregnancy, especially among high-risk women

1.2 Need for improved antenatal care

• Use of risk criteria and nationally adapted guidance to ensure high quality, timely and complete antenatal care contacts for early identification of high-risk pregnancies

• Prioritize detection, and prompt treatment and monitoring of common infections during antenatal care

1.3. Access to high quality abortion and post-abortion care

• Ensure access to safe abortion and post-abortion care services under the supervision of trained providers

1.4 Delay in seeking medical care

• Create partnerships with traditional birth attendants (TBAs) to define and agree on their roles in supporting and promoting safe health practices during pregnancy and childbirth, including early referral and access to safe abortion and post-abortion services

• Promote facility-based childbirth during antenatal care with childbirth preparedness counselling and ensure physical, financial, and culturally appropriate access to skilled and high-quality facility-based care

• Develop and implement a behavior change communication plan for women and their communities with regards to responding to danger signs during pregnancy, postpartum and post-abortion to ensure timely facility-based consultation and care by a trained health care provider

1.5 Delay in referral to higher level of care within or outside the facility

• Ensure early recognition of the need for higher level of care for pregnant or recently pregnant women at the time of admission or during their stay in a health facility to allow timely and safe referrals

• Improve communication between health care facilities, prior to, during and after referrals, including feedback to the referring facility (both positive and negative) on the referral processes and health outcomes

• Include referring health facilities and health providers in the maternal death and near-miss reviews to share insights into relevant medical history or delays that occurred prior to admission for mutual learning

2. Clinical and laboratory examinations

2.1. Need for improved clinical examination at admission and monitoring

• Introduce clinical early warning scoring systems at admission for assessment of maternal infection severity and sepsis

• Triage all pregnant and postpartum/post-abortion women at admission to ensure the right level of care for critically ill women

• Ensure routine regular and complete monitoring of vital signs at admission with regular follow-up

2.2. Microbiological culture taking

• Obtain blood culture samples, and samples from other suspected infection foci, prior to antibiotic treatment, in all cases of suspected maternal sepsis

2.3. Missing or delayed laboratory or other diagnostics

• Use adequate and complete laboratory tests to support clinical diagnosis, adequate management, and monitoring of the woman’s health condition

• Use available imaging (e.g., X-ray, ultrasound) to complement clinical diagnosis and support adequate management

3.Diagnosis

3.1. Correct diagnosis

• At arrival at the higher levels of care, re-evaluate initial diagnosis from the referring facility to influence management and outcomes

• Improve identification of infection source by ensuring a comprehensive clinical history, examination, laboratory investigation and imaging

4. Treatment and management

4.1. Antibiotic resistance and stewardship

• Ensure use of adequate antibiotic class and dose tailored to the source and severity of infection, including use of broad-spectrum antibiotics only when necessary

• Review antibiotic management based on results from bacterial culture, antimicrobial resistance profile, and clinical presentation, including avoiding changes in prescription without clear microbiological or clinical indication

• Document and monitor reasons for changes in antibiotics prescriptions, including for example availability of microbiological results, changes in clinical status, availability of antibiotics

4.2. Delayed interventions

• Remove or treat the identified infection foci as rapidly as possible

• Administer antibiotics without delay to critically ill women after securing adequate culture samples

• In critically ill septic pregnant or recently pregnant women, ensure intravenous fluid resuscitation is commenced immediately on arrival to the hospital

• Build capacity of health care providers for performance of timely and safe cesarean sections and management of post-surgical complications

4.3. Documentation and follow up

• Ensure documented medical history in early pregnancy, including pre-existing conditions and risk factors for assigning the adequate level of care

• Complete routine inpatient documentation in medical records for clinical history, clinical findings, laboratory results, treatments (dose, timing), timing of interventions, care management steps and other investigations

• Link woman-baby medical records and include maternal and newborn health outcomes as part of woman-baby dyad centered care, simultaneously where possible.

• Provide comprehensive discharge education to help women and families recognize danger signs after birth and particularly after cesarean section, for wound care and where to seek care if complications arise

5.Managing team

5.1. Unclear multidisciplinary care guidelines

• Build capacity of health care providers including at primary health care level in the recognition of danger signs of critically ill women, rapid management, and monitoring for infection-related complications.

• Establish clear criteria for when multi-disciplinary teams should manage pregnant or recently delivered women with infection in tertiary level hospitals