INTRODUCTION:

Becoming a mother is one of the most exciting times in a woman’s life. The transition from a woman to a mother is an eventful experience. The period of pregnancy, delivery and puerperium is considered as a physiologic process that affects the woman physically and emotionally.

They require special care during these periods for a safe motherhood and healthy living. Postpartum period or puerperium is the period following childbirth and is a time of physiologic stress and major psychological transmission [1]. Puerperium is of great importance for both mother and baby as it is an aspect of maternity care, where which has received relatively less attention compared with pregnancy and delivery. Majority of alarming complications arise immediately following delivery [2]. Energy depletion, fatigue of late pregnancy and labour soft tissue trauma and blood loss during delivery increase the woman’s vulnerability to complications. Puerperal infection is one among the complications and occurs at any time between deliveries of the fetus till 42 days after delivery[3]. Puerperal pyrexia and sepsis are among the leading causes of preventable maternal mortality and morbidity not only in developing countries but in developed countries as well. Most postpartum infections take place after hospital discharge, which is usually 24 hours after delivery. In the absence of postnatal follow up, as is the case in many developing countries, many cases of puerperal infections can go undiagnosed and unreported [4]. Puerperal sepsis, which is a serious form of septicemia contracted by women during or shortly after the childbirth, if untreated, is life threatening [2].

Puerperal sepsis has been described since the time of Hippocrates. The term puerperal fever, also called childbed fever was derived from the Latin word ‘puer’ which means child. The first epidemic of puerperal fever occurred at Hotel-Dieu de Paris in 1646. Hospitals in Europe and America reported death rates between 20-25 % of all women giving birth and intermittent epidemics with up to 100 % facilities in childbirth units. In 1795, Alexander Gorden of Aberdeen Scotland suggested that fever were infectious process and physicians were the carriers, for which Prof. Thomas Watson at Kings College Hospital London recommended hand washing with chlorine[5].

Puerperal sepsis occur when streptococci colonizing the genital tract or acquired nosocomially invade the endometrium, adjacent structures, lymphatic and blood stream. Postpartum birth canal remains susceptible to invasion even for several days after delivery. The predisposing factors that can lead to puerperal sepsis include births at unhygienic conditions, low socio economic status, primiparas, prolonged rupture of membranes, prolonged labour and postpartum haemorrhage[5].

Puerperal sepsis is essentially a wound infection. Raw surfaced placental site, lacerations of genital tract or caesarean section wounds can lead to sepsis through various sources. Exogenous infections come from external contamination and endogenous organisms consisting of mixed flora colonizing the woman’s own genital tract are the major sources of infection. Maternal complications include septicaemia, endotoxic shock and peritonitis or abscess formation leading to surgical intervention and compromised future fertility. Unless timely diagnosis and treatment is not carried out, it can lead to increased incidence of maternal mortality[5].

Puerperal sepsis is an important public health problem contributing to maternal mortality and morbidity [5]. Maternal mortality is defined as the death of any woman, while pregnant or within 42 completed days of termination of pregnancy irrespective of the duration or site of pregnancy from any cause related to or site of pregnancy from accidental or incidental causes. Maternal mortality rate is defined internationally, as the maternal death rate per 1, 00,000 live births. Maternal mortality rate is the sensitive index to know the quality of obstetric care[6]. Globally every year over 500,000 die of pregnancy related causes and 99 percent of these occurs in developing countries[7]. Every time a woman in the developing country becomes pregnant and her risk of dying is 200 times higher than the risk done by a woman in the developed world. New WHO global report says that globally one woman every minute due to complications during pregnancy and childbirth[8]. Despite long term efforts to reduce maternal mortality the risk of dying during pregnancy or childbirth remains significant for women in developing countries.

These countries accounted for 99 percent of the estimated 5, 36,000 maternal deaths that occurred worldwide in 20059. India continues to contribute about a quarter of all global maternal deaths[7]. Maternal mortality rate in India is 230/100000 population (2008) and 99 percent are preventable10. Much attention has been focused on prenatal care for preventing maternal mortality, though over half of all maternal deaths occur in the postpartum period[11].

Postnatal care has been unacceptably low (44%) in India given the risks of mortality for mothers and babies shortly after birth10. So, postpartum care requires immediate and intense attention[11]. Direct obstetric deaths are those resulting from obstetric complications of the pregnancy state (i.e. pregnancy, labour and puerperium), from interventions, omissions or incorrect treatment or from a chain of events resulting from any of the above. In developing countries the most causes of direct maternal death are haemorrhage, sepsis, pregnancy induced hypertension and complications of unsafe abortion[9].

A retrospective study was conducted to analyze the maternal deaths occurred during a period of 5 years at North Bengal Medical College Hospital, Darjeeling. The analysis was done during the period of January 1988 to June 1993, from the case records of Eden Hospital, Calcutta. 38, 870 delivery records were analyzed and revealed that 405 maternal deaths occurred during pregnancy, labour or within 42 days after delivery. Among them, 263 (65%) deaths occurred postpartum compared to 114(28%) in antepartum and 28 (7%) in the intrapartum period, of which sepsis 15 (5.7%) was found one of the leading causes of postpartum deaths. The study concluded that careful attention to the postpartum period can bring down maternal mortality[11].

NEED FOR THE STUDY:

India boasts of its cultural heritage and perhaps is the only country in the world to worship women goddesses, yet has perhaps the highest maternal mortality rate. India has 17.01% of total births globally and 25% of maternal deaths. Several community based studies in different parts of the country have found maternal mortality to be as high as 500-600/ 1, 00,000 (ICMR 2003). Thus a woman in India has 1 in 70 lifetime risk of dying in pregnancy or childbirth[6].

A retrospective study conducted at N.S.C.B Medical College, Jabalpur to analyze the maternal deaths occurred over a period of 15 years. The analysis was done from 1986 to 2000, where the patient population was mainly from low socio economic group, rural and urban slum areas and referrals from private clinics and adjoining district hospitals. The study revealed that the incidence of death in primigravidas was high who were from rural areas. Among direct causes, sepsis contributed 13.40% (1986-1995) to 15.10% (1996-2000) of maternal deaths[12].

Another retrospective study conducted in an urban tertiary care hospital of North India revealed the causes and complications leading to maternal mortality. The analysis was done with the medical records over a period of 4 years between January 2003 and December 2006. The study generated the information that the leading cause of maternal death were sepsis (23.84%) and the maximum deaths were occurred in between 21 and 30 of age group, while multigravida had a MMR of 51.53%, also it was highest in postnatal mothers[13].

An article published in a newspaper on maternal sepsis emerging as a killer reported that sepsis after childbirth is emerging as a significant cause of maternal mortality in Kerala. The Kerala Federation of Obstetrics and Gynaecology (KFOG), which has been conducting a confidential review of maternal deaths in the state since 2004 has reported that if in 2006 sepsis accounted for 7 percent of all maternal deaths and was its fifth leading cause, in 2009, it was the third leading cause responsible for 8 percent of all maternal deaths. Maternal sepsis accounted for death of 57 women in the postpartum period, out of a total of 676 maternal deaths in the state between 2006 and 2009. Of the 32 sepsis death reviewed by the federation 23 followed caesarean section deliveries. The KFOG’s maternal death review showed that 20 of the 32 sepsis deaths occurred within a week of delivery, indicating that these were fulminate infections (sudden, severe or lethal infections). The KFOG’s report says that pregnancy and the immediate state of the woman after childbirth are very immune-compromised states, an aggressive diagnosis and management of sepsis can prevent unnecessary loss of lives[14]. While working in maternity ward, the investigator found that the postnatal mothers were readmitted for contracting infections within 1 week after discharge due to lack of hygienic practices and inadequate preventive measures. It was observed that many postnatal mothers had inadequate knowledge regarding the measures and practices to prevent the infection during the immediate puerperal period. It has been identified that even though traditional practices are followed, they are not done in an adequate way. The mothers were found lying down with soaked perineal pads and underclothing. While conducting health educations to mothers on measures to prevent infections during puerperium, the doubts raised by them surprised the investigator and made to think the possible ways for improving the knowledge level of postnatal mothers. Maternal education and empowerment are two most important tools to reduce maternal mortality as an educated woman is more likely to accept contraception and small family norm, is more likely to eat nutritious diet and is more amenable to receive antenatal and labor care[15]. Considering the present statistical scenario and the experience made the researcher to assess the knowledge level of postnatal mothers on prevention of puerperal sepsis and to provide an information booklet regarding the prevention of puerperal sepsis.

OBJECTIVES:

· To assess the existing level of knowledge and practice of postnatal mothers on prevention of puerperal sepsis.

· To correlate the level of knowledge with practice of postnatal mothers on prevention of puerperal sepsis.

· To associate the level of knowledge of postnatal mothers with selected demographic variables.

· To develop an information booklet on prevention of puerperal sepsis.

OPERATIONAL DEFINITIONS:

Knowledge:

In this study knowledge refers to the correct responses of the postnatal mothers on prevention of puerperal sepsis elicited through structured questionnaire.

Practice:

In this study practice refers to the activity carried out by postnatal mothers based on their knowledge, recorded by researcher with a checklist as reported by the mother.

Puerperal sepsis:

An infection of the genital tract which occurs as a complication of delivery is termed as puerperal sepsis.

Postnatal mothers:

The mothers who delivered through caesarean section or vaginal route.

Information booklet:

It is a learning material prepared by researcher to provide knowledge regarding prevention of puerperal sepsis.

Assumptions:

The study assumes that:

1. Postnatal mothers may have less knowledge on prevention of puerperal sepsis.

2. Postnatal mothers may have poor practice on prevention of puerperal sepsis.

3. Selected demographic variable may influence the knowledge of postnatal mothers on prevention of puerperal sepsis

4. Information booklet helps them to gain more knowledge on prevention of puerperal sepsis.

CONCEPTUAL FRAMEWORK:

The conceptual framework for the present study was developed by using the concepts from Becker’s Health Belief Model. The Health belief model was developed by Irwin M. Rosen stock in 1966 and was furthered by Becker and colleagues in the 1970s and 1980s[16]. The Health Belief Model is an intrapersonal theory (within the individual, knowledge and beliefs) used in health promotion to design intervention and prevention programs[17]. Health belief model suggests that belief in a personal threat, together with the belief in the effectiveness of the proposed behavior will predict the likelihood of that behavior[16].

In other words, it focuses on the assessment of health behavior of individuals through examination of perceptions and attitudes that someone may have towards disease and negative outcomes of certain actions[17]. In the current study, the investigator has aimed to assess the knowledge and practice of postnatal mothers regarding the prevention of puerperal sepsis. The Health Belief Model assumes that behavior change occurs with the existence of following three components at the same time:

1. Individual perceptions

2. Modifying factors

3. Likelihood of action

Individual perception

Perceived susceptibility:

It is the individual’s opinion about how likely the behaviors they partake in are going to lead to a negative health outcome[17]. In the present study, it is the probability of the postnatal mother to contract puerperal sepsis due to the events during puerperium.

Perceived seriousness:

It addresses as how serious the disease that a person is susceptible to, can be[17]. In the present study it is the knowledge on complications of puerperal sepsis.

Modifying factors:

It refers to the outside factors that influence to affect the person and how threatened a person feels by continuing the same behaviors that put him at risk[17]. It includes the perceived threat, environmental factors and cues to action.

Perceived threat:

It is the factor which could be perceived by a person to develop into a specific disease[17]. In the present study, the perceived threat of postnatal mothers to puerperal sepsis is assessed by structured questionnaire.

Environmental factors:

It indicates the demographic factors that can add threat of a disease[17]. In the present study it includes the demographic variables like age, religion, area of residence, education, occupation, type of diet, type of family, family monthly income, source of information, number of children and type of present delivery of postnatal mothers that predispose to the disease.

Cues to action:

They are anything that triggers a decision to change the behavior[17]. In this study, cues to action are the information source regarding puerperal sepsis. It is the information booklet on prevention of puerperal sepsis given to the subjects by the researcher.

Likelihood of action:

It is the weighing out of perceived benefits and perceived barriers by the person to determine the change of behavior[17].

Perceived benefits:

It is the person’s assessment of the positive consequences of adopting a positive behavior[16]. In this study, the researcher believes that the postnatal mothers get adequate knowledge on prevention of puerperal sepsis with the help of information booklet.

Perceived barriers:

It is the person’s assessment that facilitates or discourages the adoption of a promoted behavior[16]. In this study, it indicates the poor knowledge and practice of postnatal mothers in prevention of puerperal sepsis.

Likelihood of taking recommended action:

The prediction of the model is the likelihood of the concerned person to undertake recommended preventive health action[16]. In the present study, the researcher believe that the subjects are ready to take the likelihood of recommended action by observing the significant interest of postnatal mothers in clarifying doubts after receiving the information booklet on prevention of puerperal sepsis.

Setting of the study:

Setting of the study was selected Hospitals in Pondicherry.

Population:

In this study, all the postnatal mothers constitute the population.

Samples:

In the present study, 100 postnatal mothers, who met the inclusion criteria were taken as samples.

Sampling Technique:

In this study, non-probability purposive sampling technique was used. Purposive sampling is more commonly known as judgmental or authoritative sampling, in which the subjects are chosen to be part of sample with specific purpose in mind.

Inclusion criteria:

The samples were selected with the following criteria. The study includes:

1. Mothers who are admitted in the postnatal wards of selected hospital

2. Those who can read and write Tamil or English

Exclusion criteria:

The study excludes:

1. Those who have any medical, surgical or obstetrical complications developed during antenatal, intranasal or postnatal period

Development and description of tool:

In this study, structured knowledge questionnaire and interview schedule to assess the knowledge and practice on prevention of puerperal sepsis was used. The tool was prepared by the investigator after an extensive review of research and non research literature on puerperal sepsis and discussion with experts.

Description of the tool:

Based on the objectives of the study, the following were selected as the tools

1) Demographic profile.

2) A structured questionnaire to assess the knowledge level of postnatal mothers.

3) A checklist to assess the practice of postnatal mothers through a structured interview schedule.

Part I:

A semi structured questionnaire was prepared by the researcher to assess demographic variables of the postnatal mothers. The demographic profile consists of 13 variables such as age of mother, religion, area of residence, educational status, occupation, type of diet, type of family, family monthly income, source of information, number of children, antenatal registration, antenatal immunization status and type of present delivery.

Part II:

It was a structured knowledge questionnaire on puerperal sepsis which had three sections: Section A consisted of 5 questions regarding the puerperium, Section B had 5 questions on puerperal sepsis and Section C comprised of 10 questions regarding the prevention of puerperal sepsis. All the questions were multiple choice questions. Four options were given to each question, out of which only one is the correct answer.

Part III:

It was a check list containing 10 items to assess the practice of postnatal mothers on prevention of puerperal sepsis through a structured interview schedule.

Scoring Techniques:

For Part I:

The scoring key was prepared by coding the demographic variables to assess the background of the samples and assessment of association by statistical analysis.

For Part II:

It consisted of multiple choice questions with a single correct answer. There were 20 numbers of questions. Every correct answer was accord a score of 1 point and every unanswered/ incorrect answer was accord with 0 point. The maximum score of knowledge questionnaire was 20. The obtained knowledge score was graded as follows:

Score between 0-6 Inadequate knowledge

Score between 7- 13 Moderate knowledge

Score between 14- 20 Adequate knowledge

For Part III: It was a checklist where the researcher obtained the response from the samples by a structured interview schedule. The checklist consisted of 10 questions regarding the practice in the prevention of puerperal sepsis. Presence of each practice carried 1 point and absence of behavior carried 0 point. The maximum score was 10. The obtained score was graded as follows:

Score between 0- 4 Poor practice

Score between 5- 7 Moderate practice

Score between 8- 10 Good practice

ANALYSIS AND INTERPRETATION:

The results are presented in four sections:

Section A:

Distribution of demographic characteristics of postnatal mothers.

Section B:

Assessment of level of knowledge and practice among postnatal mothers.

a. Frequency and percentage distribution of level of knowledge among postnatal mothers on prevention of puerperal sepsis

b. Frequency and percentage distribution of level of practice among postnatal mothers on prevention of puerperal sepsis

c. Area wise mean and standard deviation of knowledge scores of postnatal mothers on prevention of puerperal sepsis

d. Mean and standard deviation of knowledge and practice scores of postnatal mothers on prevention of puerperal sepsis

Section C:

Co-relation between knowledge and practice on prevention of puerperal sepsis among postnatal mothers.

Section D:

Association of level of knowledge with selected demographic variables.

Section A:

Distribution of demographic characteristics of postnatal mothers.

d) Mean and standard deviation of knowledge and practice scores of postnatal mothers on prevention of puerperal sepsis

Fig 6 Mean percentage score of knowledge and practice

Section C: Co-relation between knowledge and practice on prevention of puerperal sepsis among postnatal mothers.

Fig 7 Correlation between knowledge and practice.

Section D: Association of level of knowledge with selected demographic variables

Table 3 Association of level of knowledge with selected demographic variables

Demographic variables	Chi 2	df	P=value
Age	0.370	2	0.831
Religion	3.984	2	0.136
Residence area	1.628	2	0.443
Education	1.932	2	0.381
Occupation	2.084	2	0.353
Family type	1.904	1	0.168
Info. source	2.126	2	2.126
No. of children	0.306	1	0.580
Type of delivery	0.122	1	0.727

CONCLUSION:

Childbirth is a joyful experience for many but unfortunately it can be a difficult period bringing with it new problems that are laid down during pregnancy and childbirth. The sufferings related to childbirth make a significant portion of world’s ill health and death. Puerperal sepsis is an important public health problem which is a leading cause of preventable maternal death especially in developing countries, due to the lack of knowledge on the preventive methods. The present study shows that the knowledge is lacking even though adequate practices are existing. Also, the study reveals that there is no correlation between the knowledge and practice and unfortunately there is no association between the knowledge scores with selected demographic variables. So, the information booklet that has been provided to the samples will tackle this turmoil to an extent.

REFERENCES:

1. Dutta DC. Textbook of Obstetrics. 7th edition. India: New Central Book Agency; 2011.

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Received on 01.08.2015 Modified on 24.08.2015

Int. J. Nur. Edu. and Research 3(4): Oct.-Dec., 2015; Page 410-418

DOI: 10.5958/2454-2660.2015.00032.0

Variables	Frequency (f)	Percentage (%)
Inadequate (0-6)	9	9.0
Moderate (7-13)	90	90.0
Adequate (14-20)	1	1.0

Variables	Frequency (f)	Percentage (%)
Inadequate (0-4)	0	0
Moderate (5-7)	49	49.0
Adequate (8-10)	51	51.0