PLoS One. 2017 Jan 25;12(1):e0170856. doi: 10.1371/journal.pone.0170856.

Effect of Puerperal Infections on Early Neonatal Mortality: A Secondary Analysis of Six Demographic and Health Surveys.

Bellizzi S1, Bassat Q2,3,4, Ali MM1, Sobel HL5, Temmerman M6.

1 World Health Organization, Department of Reproductive Health and Research, Geneva, Switzerland.
2 ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.
3 Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.
4 ICREA, Barcelona, Spain.
5 World Health Organization, Western Pacific Regional Office, Manila, Philippines.
6 Department of Obstetrics and Gynaecology, Ghent University, Ghent, Belgium.




Around 1.5 million annual neonatal deaths occur in the first week of life, and infections represent one of the major causes in developing countries. Neonatal sepsis is often strictly connected to infection of the maternal genital tract during labour.


The association between signs suggestive of puerperal infection and early neonatal mortality (<7 days of life) was performed using Demographic and Health Surveys (DHS) data of six countries, conducted between 2010 and 2013. The population attributable fraction (PAF) was generated using the estimates on early neonatal mortality of a 1990-2013 systematic analysis for the Global Burden of Disease Study.


Signs of puerperal infection ranged from 0.7% in the Philippines to 16.4% in Honduras. Infection was associated with a 2.1 adjusted Risk Ratio (95% CI: 1.4-3.2) of early neonatal mortality. Around five percent of all deaths in the first week of life were attributable to signs suggestive of puerperal infections and varied from 13.9% (95% CI: 1.0-26.6) in Honduras to 3.6% (95% CI: 1.0-8.5) in Indonesia.


Targeted interventions should be addressed to contain the burden of puerperal infections on early neonatal mortality. Consideration of the PAF will help in the discussion of the benefits of antenatal and perinatal measures.

PMID: 28122046



Over the last 25 years the proportional contribution of neonates to the overall child mortality has sharply increased, being around 37% in 1990 and slightly less than 45% in 2013. There are 2.1 million of neonates dying every year, almost all in low and middle-income countries, and 75% of these deaths occur in the first seven days of life [1].

Neonatal death is mainly caused by preterm birth, asphyxia, and severe infections, which may account to up to 34% of all neonatal deaths in countries with very high mortality [2].

Up to two/fifth of infections leading to neonatal sepsis arises at the time of birth and are strictly linked to the infection of the genital tract occurring at labour, called puerperal infection, which  commonly presents with fever, pelvic pain and foul-smelling vaginal discharge [3].

While previous studies have focused on the quantification of maternal deaths due to puerperal infection [4], none has explored the same burden on neonates.

Our study revealed that the presence of symptoms related to puerperal infection doubled the risk of neonatal mortality in the first week of life. We also estimated that around one in every twenty early neonatal deaths could be avoided if puerperal infections were appropriately managed.

This translated in overall 5,756 out of 124,524 early neonatal deaths potentially prevented for five of the six countries under study (Bangladesh, Colombia, Honduras, Indonesia, and Peru).

Our findings emphasize the need of tackling maternal infections during pregnancy especially in settings scarcely equipped with diagnostic and therapeutic tools.

To contrast the bursen of puerperal infections on early neonatal mortality, a series of interventions aimed to minimize risk of infection should be enhanced, and include antisepsis measures, antibiotics prophylaxis, antenatal care and nutritional supplementation.



[1]  Lozano R, Wang H, Foreman KJ, Rajaratnam JK, Naghavi M, Marcus JR, et al. Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis.  

[2] Lawn JE, Rudan I, Rubens C. Four million newborn deaths: is the global research agenda evidence-based? Early Hum Dev. 2008; 84:809–14 

[3] World Health Organization 2009. Managing puerperal sepsis. Geneva Switzerland: WHO press. 

[4]  Buddeberg BS, Aveling W. Puerperal sepsis in the 21st century: progress, new challenges and the situation worldwide. Postgrad Med J. 2015. October; 91 (1080):572–8