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Peripartum Infections and Associated Maternal Mortality in Rural Malawi

van den Akker, Thomas MD, MSc, MPhil; de Vroome, Stefan MSc; Mwagomba, Beatrice MBBS; Ford, Nathan PhD; van Roosmalen, Jos MD, PhD

doi: 10.1097/AOG.0b013e3182254d03
Original Research

OBJECTIVE: To assess associations between maternal mortality and severe morbidity and human immunodeficiency virus (HIV) infection, uptake of antiretroviral therapy, obstetric infections, and nonobstetric infections in a rural Malawian district, where the estimated HIV prevalence is 21%.

METHODS: We studied the incidence and outcomes of maternal peripartum infections between September 2007 and September 2009 at the district hospital. We used a facility-based prospective cohort study design, including all cases of severe maternal peripartum infection up to 42 days postpartum, and recorded maternal and pregnancy-related characteristics. We assessed the association between mortality and covariates (including nonobstetric infection, HIV prevalence, and uptake of antiretroviral therapy) using univariable and multivariable logistic regression models.

RESULTS: In total, 140 infections occurred: 79 (56%) obstetric and 53 (38%) nonobstetric (eight unknown). Half of the women were HIV-positive. Multivariable analysis showed that nonobstetric infection was the most important explanatory variable for mortality (adjusted odds ratio [OR] 4.23, 95% confidence interval [CI] 1.53–11.73). HIV-positive women not on antiretroviral therapy were at higher risk of mortality (adjusted OR 3.02, 95% CI 1.06–8.60) but there was no significant mortality increase among those on treatment (adjusted OR 0.51, 95% CI 0.10–2.71). The most common infections were puerperal sepsis (obstetric, case fatality rate 7%) and pneumonia (nonobstetric, case fatality rate 41%).

CONCLUSION: Untreated HIV infection and nonobstetric infections are independently associated with maternal mortality. Prompt treatment of HIV and nonobstetric infections in pregnant women must be prioritized to reduce maternal mortality.


Maternal mortality from peripartum infections is more common in women with nonobstetric infections and HIV-positive women not on antiretroviral therapy.

From the Thyolo District Health Office, Ministry of Health, Thyolo, Malawi; Médecins Sans Frontières Operational Center Brussels, Brussels, Belgium; the Department of Medical Humanities, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands; the Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands; and the Center for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa.

Corresponding author: Thomas van den Akker, MD, MSc, MPhil, VU University Medical Center, EMGO Institute for Health and Care Research, Department of Medical Humanities, Van der Boechorststraat 7, 1081BT Amsterdam; e-mail:

Financial Disclosure The authors did not report any potential conflicts of interest.

© 2011 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.