The Italian Obstetric Surveillance System (ItOSS)

Maternal and perinatal sepsis: the WHO Global Maternal Sepsis Study (GLOSS)

Sepsis is one of the leading global causes of maternal and neonatal death [1-3]. The World Health Organization (WHO) estimated that, between 2003 and 2009, sepsis accounted for 10.7% of maternal deaths [1]. A systematic review in 2013 found that sepsis was responsible for 15.6% of neonatal deaths globally [2]. In countries with a high level of economic development, available data show an incidence of between 9 and 49 cases per 100,000 maternities per year and the high case fatality rate of this condition [3]. The lack of standard definitions, validated identification criteria and effective tools to predict a diagnosis are the main sources of uncertainty in estimating the impact of the condition in maternity care. A clear and common definition of sepsis, which would facilitate national and international comparisons and allow assessments of both its frequency and the effectiveness of treatment approaches, is of the utmost importance also to reduce and/or prevent deaths caused by sepsis [4].

In 2017, as part of the “Global Maternal and Neonatal Sepsis Initiative” [5-7], which aims to accelerate the reduction of preventable maternal and neonatal deaths related to sepsis worldwide, the WHO launched the multicentre “Global Maternal Sepsis Study” (GLOSS): over the course of one week (between 28/11/2017 and 04/12/2017), data were collected on all women with suspected or confirmed infection, during any stage of pregnancy and up to 42 days after the end of pregnancy, who spent at least 12 hours in a participating healthcare facility [8]. The primary objectives of this project included: validating a set of criteria for early identification of maternal sepsis in low- and high-income countries; estimating incidence rates; describing and analyzing the outcomes of suspected or confirmed cases of sepsis among the women and their newborn babies. A follow-up study was conducted, only in the European countries, to describe the use of antibiotics in the treatment of maternal sepsis, and to investigate the condition of migrant women as well as possible variability in treatment protocols for the management of severe infections in that population. Fifty-eight countries simultaneously took part in the multicentre study. The European countries involved (Belgium, Denmark, the Netherlands, Spain, the United Kingdom, Slovakia and Italy) are all part of the International Network of Obstetric Survey Systems (INOSS), which conducts multicentre studies on severe maternal morbidity [9].

Italy’s collaboration with GLOSS

Through linkage of cause of death certificates to hospital discharge records (Schede di Dimissione Ospedaliera - SDO) in 8 Italian regions, accounting for 73% of total births across the country, ItOSS estimated the ratio of maternal mortality from sepsis at 0.2/100,000 live births over the period 2006-2012.

Data from the ISS-Regions active surveillance showed an increase in maternal death from sepsis over time, as the condition rose from being the fourth most frequent cause of maternal mortality in 2006-2012 to the second most frequent in 2013-2015.

Designated by the World Health Organization as the focal point for maternal mortality estimates in Italy [10], ItOSS was invited to take part in GLOSS. Data collection, based on the case definitions adopted by the study, was conducted in Lombardy (the region with the highest number of maternities in Italy - 85,708 in 2014, or about 17% of the total [11]), with the valuable cooperation of the network of health professionals participating in the ISS-coordinated obstetric surveillance.

GLOSS: study population and procedure

The population-based cross-sectional study reviewed information about all women with suspected or confirmed infection, during any stage of pregnancy and up to 42 days after the end of pregnancy, who spent at least 12 hours (between 00:00 on 28/11/2017 and 24:00 on 04/12/2017) at public or private healthcare facilities with obstetric and neonatal units or a neonatal intensive care unit.

The study, also promoted by the Global Sepsis Alliance (GSA), aimed to shed light on the global burden of maternal and neonatal sepsis among health professionals, policy-makers and the general population, including pregnant women, mothers and their families. To help reduce preventable maternal and neonatal deaths, the WHO deemed it strategic to organize a global data collection effort that allowed sharing a common definition of sepsis in maternity care, which is essential for future quality research.

In Europe, taking into account the emergence of antimicrobial resistance and the “European One Health Action Plan against Antimicrobial Resistance” [12] adopted by the European Commission to promote national policies for appropriate use of antimicrobials, GLOSS aims to shed light on the use of antibiotics for the treatment of maternal and neonatal sepsis and infection. In the light of growing migratory flows, GLOSS will also provide healthcare workers with tools designed to effectively meet the need to protect the health of migrants.

In Italy, GLOSS dovetails with the population-based project on severe maternal morbidity, which focuses on four obstetric emergencies, including sepsis, and involves 9 regions of the ISS obstetric surveillance network, accounting for 75% of total births in the country (see the page dedicated to the severe maternal morbidity project).

References

1. Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, Gülmezoglu AM, Temmerman M, Alkema L. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2014;2(6):e323-33
2. Chan GJ, Lee AC, Baqui AH, Tan J, Black RE. Risk of early-onset neonatal infection with maternal infection or colonization: a global systematic review and meta-analysis. PLoS Med. 2013;10(8)
3. Oud L. Pregnancy-Associated Severe Sepsis: Contemporary State and Future Challenges. Infect Dis Ther 2014;3(2):175-89
4. Bonet M, Nogueira Pileggi V, Rijken MJ, Coomarasamy A, Lissauer D, Souza JP,Gülmezoglu AM. Towards a consensus definition of maternal sepsis: results of a systematic review and expert consultation. Reprod Health. 2017;14(1):67
5. The Global Maternal and Neonatal Sepsis Initiative: a call for collaboration and action by 2030. Lancet Glob Health 2017;5(4):e390-e391
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8. WHO Global Maternal Sepsis Study (GLOSS) Research Group. Frequency and management of maternal infection in health facilities in 52 countries (GLOSS): a 1-week inception cohort study. Lancet Glob Health. 2020;8(5):e661-e671. doi:10.1016/S2214-109X(20)30109-1
9. Knight M, INOSS. The International Network of Obstetric Survey Systems (INOSS): benefits of multi-country studies of severe and uncommon maternal morbidities. Acta Obstet Gynecol Scand 2014; 93: 127-31
10. Donati S. Maternal mortality estimates. Lancet 2014;384(9961): 2210
11. Rapporto sull'evento nascita in Italia (CeDAP) relativo all'anno 2014. A cura di Ministero della Salute. Anno 2017
12. WHO.org. Drug resistance: Antimicrobial resistance: global report on surveillance 2014.