Puerperal (around the time if childbirth) fever is a highly infectious disease that resulted in significant maternal mortality (deaths) from the seventeenth to the nineteenth centuries, and still remains a potential threat in developing nations. It is caused most often by infection from Group A streptococcal bacteria during or immediately following childbirth and is transmissible between patients. During the historic epidemic periods, infection almost always proved fatal and mothers exhibited symptoms of fever, abdominal pain, and vaginal hemorrhage.
Puerperal fever was not prevalent in developed nations until the seventeenth century, when it became common for women to give birth and recover in hospitals. Hospital physicians were responsible for the examination and deliveries of many pregnant women each day. It was these routines that eventually indicated that doctors and nurses were responsible for transmitting the disease between patients. Physician and professor Oliver Wendell Holmes (1809–1894) and physician Ignaz Semmelweis (1818–1865) were each independently responsible for increasing awareness of this mode of transmission and implementing preventative measures against further spread of infection. In developed nations, puerperal fever poses little significant risk to expecting mothers.
Puerperal fever, also referred to as childbed fever or puerperal sepsis, was a disease commonly affecting mothers during or shortly after childbirth up until the twentieth century. The first case of puerperal fever that was documented occurred in Paris in 1646, but it was not until 1879 that Louis Pasteur (1822–1895) identified the causative agent as bacteria belonging to the Streptococcus group.
Following childbirth, the placental attachment site in the uterus remains an open wound highly susceptible to infection from bacteria that occur normally on the skin, nose, throat, and vagina. Following infection by Streptococcus bacteria, the disease presents with rapid onset of fever, abdominal pain, abnormal vaginal discharge, and bleeding. Infection usually occurs within ten days of birth, and progresses to septicemia (bacterial infection in the blood) or peritonitis (generalized infection of the lining of the abdomen). During periods of epidemics, puerperal fever carried a fatality rate of up to 100 percent.
The significant prevalence of puerperal fever began only after the establishment of lyingin hospitals, wherephysicians were completing many deliveries each day and treating many women who had given birth each day. Practitioners at that time were attending a number of patients each day without using sterilization procedures between patients. In 1843, Oliver Wendell Holmes concluded that physicians and nurses were responsible for transmitting the infection through their hands and clothing.
WORDS TO KNOW
MORTALITY: Mortality is the condition of being susceptible to death. The term “mortality” comes from the Latin word mors, which means “death.” Mortality can also refer to the rate of deaths caused by an illness or injury, i.e., “Rabies has a high mortality.”
PUERPERAL: An interval of time around childbirth, from the onset of labor through the immediate recovery period after delivery.
SEPTICEMIA: Prolonged fever, chills, anorexia, and anemia in conjunction with tissue lesions.
Unaware of this prior conclusion, physician Ignaz Semmelweis of Hungary noticed that one ward of physicians in his hospital had a 16 percent fatality rate compared with the midwife wards, which had a 2 percent fatality rate. Semmelweis recognized that the physicians had been performing autopsies on puerperal fever patients prior to deliveries, and concluded that the physicians were spreading the infection from patient to patient. Semmelweis then introduced mandatory washing with chlorinated lime at the beginning of shifts and prior to vaginal examination. Mortality was subsequently reduced to less than 3 percent.
Although puerperal fever had a relatively recent period of significant endemnicity during the eighteenth and nineteenth centuries, it has been recognized for thousands of years that delivering women may be at risk of a fever that could be fatal. However, the mortality rates of puerperal fever in ancient and medieval times were lower, as women generally gave birth at home and were therefore not at risk of exposure to infection carried by attending medical staff.
Today, in developed countries, deaths from puerperal fever are rare and the mortality rate is about 0.1 per 10,000 births. This significant reduction in fatalities is largely attributed to improvements in sanitation and hygiene during birth, as well as the use of antibiotics to treat bacterial infections. Those at increased risk of developing puerperal fever are women with compromised immunity, women who are anemic, and women who endure a long labor.
In developing nations, childbirth-related fatalities remain a considerable threat to women, with 95 percent of maternal deaths occurring in Africa and Asia. In developing countries, around 1 in 16 births are fatal compared to 1 in 2,800 among developed countries. The exact causes of these deaths are often not determined, but puerperal fever is often a significant contributing factor. This substantial risk is due to a lack of healthcare training and facilities, which increases the risk of patients developing puerperal fever. Poor health care facilities also reduce the chances that the infection will be effectively treated.
IN CONTEXT: BIRTHS ATTENDED BY SKILLED HEALTH PERSONNEL
The list below reflects data from countries reporting that less than half (50%) of all births are attended by skilled health personnel as reported by the World Health Organization in February 2007. Data was not available or published for all countries, including Sudan and Congo.
- Ethiopia: 5.6 % (2000)
- Nepal: 10.9 % (2001)
- Bangladesh: 13.4 % (2004)
- Afghanistan: 14 % (2003)
- Chad: 14.4 % (2004)
- Niger: 15.7 % (2000)
- Lao People's Democratic Republic: 19.4 % (2001)
- Yemen: 21.6 % (1997)
- Pakistan: 23 % (2001-02)
- Timor-Leste: 23.6 % (2002)
- Bhutan: 23.7 % (2000)
- Haiti: 23.8 % (2000)
- Burundi: 25.2 % (2000)
- Eritrea: 28.3 % (2002)
- Rwanda: 31.3 % (2000)
- Cambodia: 31.8 % (2000)
- Somalia: 34.2 % (1999)
- Guinea-Bissau: 34.7 % (2000)
- Guinea: 34.8 % (1999)
- Nigeria: 35.2 % (2003)
- Uganda: 39 % (2000)
- Mali: 40.6 % (2001)
- Guatemala: 41.4 % (2002)
- Kenya: 41.6 % (2003)
- Sierra Leone: 41.7 % (2000)
- India: 42.5 % (2000)
- Zambia: 43.4 % (2001-02)
- Central African Republic: 44 % (2000)
- United Republic of Tanzania: 46.3 % (2004-05)
- Angola: 47.1 % (2000)
- Ghana: 47.1 % (2003)
- Mozambique: 47.7 % (2003)
- Togo: 48.6 % (2000)
SOURCE: World Health Organization, WHO Database on Skilled Attendant at Delivery. World Health Organization (http://www.who.int//reproductive-health/global_monitoring/data.html).
During periods when puerperal fever was epidemic, the rapid onset of infection, the ease of transmission between patients, and the lack of knowledge regarding causation made both treatment and prevention impossible. Until the causative agent and mode of transmission could be understood, puerperal fever remained an almost certain threat among maternity wards.
The discovery by Oliver Wendell Holmes and Ignaz Semmelweis that medical birthing attendants were responsible for transmitting infection between patients was revolutionary in the fight against puerperal fever. Due to these realizations, practices were established to ensure physicians did not spread the infection. These practices included changing clothing between births, washing of hands with chlorinated solutions before and after attending to patients, and sterilizing implements used during childbirth. These practices are still followed as a defense against childbirth infections.
Once it was established that puerperal fever was a result of infection by Streptococcus bacteria, treatment of infection also became possible. The use of intravenous antibiotic regimes from the onset of labor through to delivery, especially in prolonged and complicated labors, can effectively treat mothers at risk for puerperal fever.
Although the impacts of puerperal fever have been diminished in the developed world since physicians gained an appreciation of the nature of the disease, it remains a significant threat to expecting mothers in developing nations.
One of the main issues of this disease is that the Streptococcus bacteria responsible for causing infection are part of the normal flora of the skin, nose, throat, and vagina. This means that potentially every woman is at risk of developing infection during or following childbirth even in the absence of an outside reservoir of the contagion. In developed countries, problematic births are often predicted prior to the event and physicians can take a suitable course of action to prevent further complications associated with such infections. Such measures are not available to the majority of women in developing nations.
There is also a lack of healthcare training among developing countries, including medical personnel who do not entirely understand the mechanisms of disease. This can lead to medical personnel passing the infection from patient to patient. This makes it more likely for women in developing nations to develop puerperal fever, while reduced health care resources also makes it more likely that the infection will be fatal.
Further issues exist for the children born from maternally fatal deliveries as they are often instantly subject to disadvantage. Until they reach a certain age, they are unable to contribute to labor and productivity but remain a strain on essential resources such as food and water. The society may view them as a liability rather than a member of the community, which results in significant social impact.
At the United Nations Millennium Summit in 2000, world leaders established a set of goals to combat certain sources of poverty, illness, illiteracy, hunger, and environmental problems. These goals are commonly referred to as the U.N. Millennium Goals. One of the primary development and health goals is to reduce the maternal mortality ratio by 75 percent by 2015. Worldwide, maternal mortality is highest among poor and rural women in developing nations.
While noticeable improvements in the maternal mortality ratio have occurred since the inception of the Millennium Development Goals in 2000, maternal mortality remains high in the regions where women are most likely to die from childbearing, especially sub-Saharan Africa and Southern Asia. Puerperal sepsis continues to be a significant problem. Researchers and health care providers found that women who had a skilled attendant during childbirth—along with access to emergency care if needed—were less likely to die or suffer debilitating complications. Overall, only 56% of women in developing regions have a skilled health care attendant during childbirth. In sub-Saharan Africa, only 36% of women have a skilled attendant assist their birth, compared to 88 percent of women in Latin America.
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