Knowledge and Practices of Postnatal Mothers Regarding Prevention of Puerperal Sepsis

Introduction  

Puerperal sepsis is infection of the genital tract occurring at the period between the rupture of membranes or labor, and the 42 days of postpartum. puerperal sepsis can cause long-term health problems such as chronic pelvic inflammatory disease (PID) and infertility. Puerperal sepsis is the fourth common cause of maternal mortality after postpartum bleeding, unsafe abortion and hypertensive disorder of pregnancy. It causes about 8% of maternal deaths Globally 6 million had developed puerperal sepsis and around 77,000 mothers died of it. (Atlaw& Seyoum, 2019).  puerperal sepsis,divided to local infection as rise of temperature, malaise, headache, redness and swelling of episiotomy, pus formation in the episiotomy, and uterine infection as rise of temperature with chills and rigor, rapid pulse, copious and offensive lochia discharge, subinvoluation of uterus, breathlessness abdominal pain and dysuria and spreading infection (sepsis) as parametritis, pelvic peritonitis, and pelvic abscess (Kaur, 2019).    The most effective and least expensive treatment of postpartum infection is prevention. Preventive measures include, good prenatal nutrition to control anemia and intrapartal hemorrhage. Good maternal perineal hygiene with thorough hand washing is emphasized. Nurses in birth centers and hospital settings must be able to identify women at risk for postpartum infection and to provide anticipatory teaching and counseling before discharge. After discharge, telephone follow-up, hot lines, support groups, lactation counselors, home visits by nurses, and teaching materials (videos, written materials) are all interventions that can be implemented to prevent or increase recognition of postpartum infections
(Lowdermilk, et al.,2016).                                                                                          

Significance of the study   :

World Health Organization (WHO) estimated that about 350,000 maternal deaths occur during labor and childbirth of which 15% were associated with puerperal sepsis. Puerperal sepsis causes at least 75,000 maternal deaths every year and mostly occurs in low-income countries with a distribution of 11.6% in Asia, 9.7% in Africa, 7.7% in Latin America and the Caribbean compared to the 2.1% in developed countries (WHO, 2016). In Nigeria, puerperal sepsis accounted for 12% of maternal deaths In Ethiopia, puerperal sepsis accounted for about 13% of all maternal deaths and became one of the top four causes of mortality (Admas, et., al. 2020).    postnatal infection is the fourth direct leading cause of death in Egypt,  according to a recent study in Upper Egypt done by Masoud and Saber , (2016) Effectiveness of Puerperal Sepsis Self-Care Guideline on Women's Health during Pueriperium concluded that puerperal sepsis was  2% among studied sample
(Masoud & Saber, 2016).

Subjects and Methods

Aim of this study

This study aimed to assess the knowledge and practices of postnatal mothers regarding the prevention of puerperal sepsis.

Research Questions

-          What are the knowledge of postnatal mothers about puerperal sepsis?.

-          What are the practices of postnatal mothers about puerperal sepsis?.

-          Is their are association between knowledge and practices of postnatal mothers regarding puerperal sepsis?.                      

Research Design

A descriptive cross-sectional research design was utilized to fulfill the aim of this study.

Setting

 The study was conducted at the postnatal department of obstetric and Pediatric (MUHOP) during the first day of postpartum period .

Sample:

A purposive sample composed of 87 postnatal mothers participated in the current study according to following criteria.

Sample technique:

N = 87 women

Description:

• N = required sample size.
• t = Confidence level at 95 % (standard value of 1.960).
• p = Prevalence of    (0.07).
• m = Margin of error at 5 % (standard value of 0.050). 

Inclusion Criteria:

• Postnatal mothers who were inpatient word during the first day of postpartum.
• Postnatal mothers who were free from any infection.
• Who delivered normally.
• Willing to participate in the study.

Exclusion Criteria

• Who delivered the cesarean section?
• Women with chronic disease.

Tools for Data Collection

To achieve the goal of the study, data was collected through using three tools designed by the researcher after reviewing the related literature.                                       

Tool I: A structured interview questionnaire, it consisted of two parts (Chepchirchir, et al., 2017).

Part (one): Socio-demographic characteristics such as (age, residence, educational level, occupation, income, and the source of women's knowledge about puerperal sepsis).

Part (two): this part involved obstetric history such as(gravidity, parity, and  multiple pregnancies, methods of current delivery, number of living children).

Tool II: knowledge assessment tool: it used to assess women's knowledge  regarding puerperal sepsis included (14 ) items in the form of closed questions related to the normal postpartum period (definition, duration and changes of postpartum period) and concept of puerperal sepsis (definition, risk factors, signs and symptoms, complication, prevention and it’s management).

Scoring system of women's knowledge

The mother's answers related to knowledge regarding puerperal sepsis include (14) items were scored and calculated. A scoring for mothers' knowledge was consisted of given (2) for complete correct answer, (1) for incomplete correct answer and (0) for incorrect answer or for any woman who didn't know the answer. These scores were converted into a percent score, A score was given to each question and the total knowledge score was range from (o%) to point score knowledge below 60% classified as unsatisfactory and mother's had 60% and more was described as satisfactory knowledge.

Tool III: Practical Assessment Tool: it used to assess postnatal mother's practices regarding prevention of puerperal sepsis involved (24) items as (maintain a healthy hemoglobin level, ensure a balanced diet, have plenty of fluid intakes, maintain good hygienic care especially around perineum, keep the area dry, ventilated and clean, monitor vital parameters such as pulse and body temperature, wash hands before and after using bathroom, perform perineal care from front to back…….etc.) (Sultana et al., 2018).

Scoring System for postnatal mother's practices

                The done practice was scored as (One) while not done practice was scored as (Zero). The total practice scores were 24 scores; these scores were converted into a percent score. The total score of mother's practices was classified as follows:  mothers were considered good practices when the total score was 60% and more .poor practices when the total score is less than 60%. 

Validity and Reliability     

The tool was tested for content validity by a jury of five experts in the field of Obstetrics and Gynecological nursing staff and nursing professor who reviewed the instruments for clarity, relevance, comprehensiveness, understanding, applicability, and easiness, to establish the reliability and statistically done Alpha Cronbach way to check the stability of the internal consistency of the instrument was .781 and 0.810 respectively.

Pilot Study:

After developing the tools, a pilot study was conducted on 10% (9 women) of cases to test the feasibility and applicability of the tools used in the current study for data collection as well as to determine the time required to be applied and modifications were done of some items of the questionnaire and the woman who were tested in the pilot study weren't included in study sample.

Data collection procedure:

An official letter was requested from the Dean of the faculty of Nursing at Minia University to the director of Minia University Hospital for Obstetric and Pediatric (MUHOP) asking for permission to collect data. Meeting with selected place managers to explain the objectives and aims of the study who helped to gain their cooperation and allow meeting the postpartum women. 

The investigator was attending to the selected hospital to collect the datafrom 8.30 AM to 1.30 PM on two days each week (Saturday and Sunday) for three months. The investigator was collect data from inpatient words during the first day of postpartum from 5 to 8 women each week .

All women were informed that their participation is voluntary and reassurance was given to the women about the confidentiality of their responses. The investigator explained the aim and nature of the study briefly through direct personal communication that it took time from 20-30 minutes with the participants. Oral consent was obtained from the participants before inclusion in the study.

After that, the investigator filled the questionnaires from women who participated in the study. The investigator assesses woman's knowledge and practices through asking all questions that present in questionnaires (tool II, III). The time consumed for completing the questionnaires was ranged from 30-45 minutes .The duration of data collection was started from the first of July 2020 to the end of September 2020. At the end of data collection, the investigator gave women advice and instructions about how to prevent puerperal sepsis.

Ethical Consideration:

Written initial approval was obtained from the dean of the Faculty of Nursing and the research ethics committee of the Faculty of Nursing, Minia University. Oral informed consent was obtained from women who participated in this study. Each assessment sheet was coded and postnatal women's names did not appear on the sheets for anonymity and confidentiality.

Statistical Design:

Data entry was done using a compatible personal computer. Statistical analysis was done by using the statistical package of social science (SPSS, IBM) version 25. The content of each tool was analyzed, categorized, and then coded. Data were presented using descriptive statistics in the form of frequencies and percentages for qualitative variables, and means and standard deviations for quantitative variables. Graphs were done for data visualization using Microsoft Excel. Statistical significance was used at P-value <0.05. Chi-square/ or fisher exact test was used to detect the relation between the demographic characteristic of postnatal women with their knowledge and practices. Pearson correlation tests were used between quantitative data.

Results:

Part I: Socio-demographic characteristics and obstetric history among studied sample

Table (1): Frequency distribution of the studied sample regarding to their socio-demographic characteristics (n= 87)

Table (1): shows that 31.1% of the studied sample aged ranged between 28 – 33 years with mean age 29.3 ± 5.14 years, 71.3% of them lives in rural area, 35.6% of them illiterate, and 83.9% of them were housewives.

Figure (1): Percentage distribution of the studied sample regrading to their sources of knowledge (n = 87)

Figure (1): illustrates that 52.9% of the studied women their source of knowledge was their mothers, followed by 41.4% of them was their friends and relative, 36.8% of them was their physician, 27.6% of them was nurses and 18.4%, 9.2% , and 4.6% were television, social media and reading respectively.

Figure (2): Percentage distribution of the studied sample regrading to their total knowledge levels

about puerperal sepsis (n = 87).

                Figure (2): illustrates that 87.4% of the studied women had unsatisfactory knowledge level and 12.6% of them had satisfactory knowledge level regarding prevention of puerperal sepsis.

Figure (3): Percentage distribution of the studied sample regarding to their total practice levels

about puerperal sepsis (n = 87).

figure (3): illustrates that 74.7% of the studied sample had poor practice about prevention of puerperal sepsis and 25.3% of them had good practice regarding it.

Table (2): Relation between total knowledge level of the studied sample with their total practices' levels about puerperal sepsis (n = 87).

**statistically significance differences at < .01

Table (2): reveals that 80.3% of the studied sample have unsatisfactory knowledge had poor practice level to prevent puerperal sepsis and 63.6% of them who had satisfactory knowledge had good practices with highly statistically significance differences P – value < .002.

Table (3): Correlation matrix between studied sample age, educational level, total practice score, and total knowledge scores (n = 87).

Table (3): presents that positive fair association between studied sample age with their total knowledge score (r=.317 & P – value < .003), educational level with their total knowledge and practice scores (r=.290& P – value < .006; r=.386& P – value < .0001 respectively), and their total practice level with their total knowledge score (r=.431 & P – value < .0001).