We sat down with Vanessa Brizuela, DrPH, to learn more about her recent research project related to global maternal infections. Dr. Brizuela completed her DELTA project on the development of the awareness campaign that accompanied the global maternal sepsis study (GLOSS). She moved to Geneva, Switzerland to do this and to support the coordination of the global study. Vanessa holds a masters degree in Health Education from Teachers College at Columbia University and a Licensure in Psychology from the University of Buenos Aires in Argentina, her home country.
The GLOSS study coordination team in Geneva was comprised of Mercedes Bonet, PhD, and João Paulo Souza, PhD, both medical officers at the World Health Organization at the time. They led the development of the new definition for maternal sepsis, the launch of the Global Maternal and Neonatal Sepsis Initiative, and the protocol for GLOSS. Dr. Bonet leads the portfolio around maternal infections and sepsis at the World Health Organization and Dr. Souza is now a full professor and Head of Department of Social Medicine at the University of São Paulo in Riberão Preto, Brazil.
Thanks for speaking with us. To start off, can you tell us why you were interested in conducting this research in the first place?
Thank you for inviting me to speak with you. Being part of this study has been very powerful.
Sepsis remains a leading cause of maternal death for women during and after pregnancy. If we can understand why that is, we will be better equipped to combat it. The first step towards this was to establish the Maternal and Newborn Sepsis Initiative in collaboration with Jhpiego and supported by many partners, including the MHTF. Our aim was to learn more about maternal sepsis, and maternal infection which can lead to sepsis, through research, collaboration, innovation, and advocacy. Together, we embarked on the Global Maternal Sepsis Study, or GLOSS. This ambitious study was implemented in over 50 low-, middle-, and high-income countries around the world to obtain data on the frequency and management of maternal infections and sepsis.
Why is it difficult to assess maternal infections, and how has this difficulty hampered our ability to prevent them in the past?
Maternal infections have historically been difficult to identify and manage for many reasons. Infections present with different signs and symptoms depending on the source and severity. Pregnancy also brings on many physiological changes in a woman’s body which may make the early identification of infection or sepsis more difficult.
Maternal infections also reveal issues beyond the individual factors, such as the availability of antibiotics, or the challenges of access to clean water, sanitation, and hygiene in health facilities. Preventing and managing infections requires a clear understanding of all of the issues involved as well as concerted efforts to address them.
Can you briefly describe your study and what you found?
GLOSS was a facility-based cohort study, and we simultaneously enrolled women in all participating facilities during one week in 2017. We collected data on how infections were identified and managed among pregnant and recently pregnant women in different settings (labor and delivery wards, gynecology wards, intensive care units, emergency departments) in over 700 facilities in 52 countries.
The data collection was accompanied by a campaign for health care providers working in those facilities, aiming to increase their awareness and understanding of maternal sepsis identification and management.
GLOSS found that infection has a much larger impact on global maternal mortality and morbidity than previously thought. Results from our study showed that about 70 hospitalised women per 1000 livebirths had a maternal infection and 11 women per 1000 livebirths had an infection-related severe maternal outcome. GLOSS also provides a more complete understanding of maternal infections, which is crucial for reducing preventable maternal deaths and injury.
This is because we assessed infection across the pregnancy and post-pregnancy continuum and were able to identify adverse maternal outcomes where infection was not necessarily the main cause but a contributing factor to mortality. In addition, we were able to report not only on direct (obstetric) infections during pregnancy and postpartum, but also on post-abortion infections and indirect infections (non-obstetric).
Your study also included an awareness campaign of maternal sepsis and its risk factors among health care providers. Why did you decide to include the campaign?
The campaign was, in part, a response to an important World Health Assembly 2017 resolution and the Initiative urging for increased awareness on sepsis. We believed that including the campaign could not only help increase awareness, but also ensure that health care providers engaged with GLOSS were better able to identify maternal sepsis.
The campaign also provided an opportunity to engage all study implementers through the materials we developed. And they engaged! Many country partners developed creative educational materials, with flyers, bookmarks, t-shirts, and videos to increase awareness on maternal sepsis in their facilities and beyond. You can find many of these examples in the news section of the GLOSS website.
What role do you think the awareness campaign played in the results of your study?
GLOSS participants told us that the campaign and the study made the issue of maternal infections and sepsis come alive again, with many more healthcare providers in the facilities talking about this critical issue.
The campaign increased both knowledge around maternal sepsis and confidence in knowing what needed to be done to manage it, as we show in our recent publication.
It also encouraged local research teams to engage with providers by displaying materials and developing site-specific actions and activities: for instance, one partner decided to expand the campaign to cover the entire country, while another used this initiative to push for policy recommendations accompanied by another campaign.
You can read about these experiences here and here.
Do you have any advice to other researchers looking to incorporate a health campaign into their research process?
First of all, make sure you know what the goals are for incorporating a health campaign into a research project. Plan well, including an evaluation component. There are a lot of campaigns and messages out there, so make sure that you know why you want to do this and are able to say how your campaign contributed to the study outcomes.
It is essential to work with local researchers and providers for insight and input into your campaign and any materials that are developed. You want to make sure that everything produced is genuinely useful and informative for local partners and their communities.
Finally, an awareness campaign is not a small ‘add on’ to a research project. You will need to have a dedicated campaign point person to manage all aspects related to the campaign, to support the implementers in the field, and to lead in the evaluation of it.
What is next for the campaign and your research?
We will be publishing additional results from the study, including on antibiotic use for maternal infections, neonatal outcomes, facility response and compliance with certain clinical assessment and maternal outcomes. This will help inform and strengthen our response as we continue our work towards the urgent goal of reducing maternal mortality and morbidity.
Additionally, WHO will later this year be publishing a global sepsis epidemiology report in response to the World Health Assembly resolution. This includes data on global maternal infections and sepsis.
While the active period of the campaign ended around the time we ended data collection, we have made all the materials available free to download for anyone working with pregnant or recently pregnant women.
Is there anything we didn’t ask you that we should have?
I would like to invite all your readers to find out more about the study, the results, and the campaign by reading more on the WHO website, and by visiting the GLOSS website.
All the materials we created for the campaign are free, editable and available for download – so please use them widely and join us as we work together to stop maternal sepsis.
Useful links:
- Frequency and management of maternal infection in health facilities in 52 countries (GLOSS): a 1-week inception cohort study
- Early evaluation of the ‘STOP SEPSIS!’ WHO Global Maternal Sepsis Awareness Campaign implemented for healthcare providers in 46 low, middle and high-income countries
- GLOSS website
- WHO maternal sepsis website
- WHO Improving the prevention, diagnosis and clinical management of sepsis
- MHTF story on maternal sepsis