Self-Care Practices for Puerperal Sepsis Prevention and Associated Factors Among Postnatal Women in Africa: A Systematic Review and Meta-Analysis

Abstract

Background

Puerperal sepsis remains a preventable contributor to maternal illness. Pregnancy-related sepsis is responsible for ∼10% to 15% of maternal deaths. Despite this burden, no comprehensive review has examined self-care practices related to its prevention. Therefore, this review sought to evaluate self-care behaviors aimed at preventing puerperal sepsis and to explore associated factors among postnatal women in Africa.

Data Sources and Methods

We conducted a systematic review and metaanalysis of 17 eligible studies on the prevalence of self-care practices for puerperal sepsis prevention and their associations among postnatal mothers. Searched PubMed, Web of Science, Wiley Online Library, ScienceDirect, African Journals Online, and Google Scholar from December 10, 2023 to January 15, 2024. A Joanna Briggs Institute adapted tool was used to assess the quality of the studies. Forest plot, Cochran's Q test, subgroup analysis, sensitivity analysis, and metaregression model were used to test heterogeneity between included studies. Funnel plots and Egger's test were used to examine publication bias.

Results

A total of 17 studies that meet the inclusion criteria were included. The pooled prevalence of self-care for puerperal sepsis prevention practices among postpartum women was 36.09% (95% CI: 26.35, 45.82). Among postpartum women, urban dwellers (AOR: 3.23, 95% CI: 1.86, 5.63), those who were above tertiary education status (AOR: 2.81, 95% CI: 1.11, 4.67), those who had a good level of knowledge (AOR: 2.45, 95% CI: 1.11, 4.67), and those who had ≥4 ANC contacts (AOR: 3.75, 95% CI: 2.23, 6.31) were identified as associated factors.

Conclusions

Only 36.09% of postpartum women practiced self-care practices to prevent puerperal sepsis at home. It would be better to design a new healthcare system during maternal healthcare to scale up mothers’ self-care puerperal sepsis prevention practices to reduce maternal morbidity and mortality caused by puerperal sepsis. In addition, all healthcare providers recognize the need to foster new thinking and to apply greater action to address identified factors of poor self-care and puerperal sepsis prevention practices.

PROSPERO Registration

CRD420251042794.

Plain Language Summary

Self-care practices for puerperal sepsis prevention and associated factors among postnatal women in Africa: A systematic review and meta-analysis

Puerperal sepsis remains a preventable contributor to maternal illness. Pregnancy-related sepsis is responsible for ∼10% to 15% of maternal deaths. Although some primary studies have been conducted on self-care prevention practices and related factors, the findings have been inconsistent, making it difficult to generalize their results across Africa. Therefore, this systematic review aimed to evaluate the overall self-care prevention practices and their associated factors among postpartum mothers. I hope our findings will help to identify relevant gaps and contribute to improving self-care practices to prevent complications of puerperal sepsis and encourage early self-reporting about the condition. In addition, all healthcare providers recognize the need to foster new thinking and to apply greater action to address identified factors of poor self-care and puerperal sepsis prevention practices.

Keywords

self-care practice puerperal sepsis prevention postpartum mother Africa

Introduction

Puerperal sepsis is an infection of the genital tract that may arise any time from the rupture of membranes up to 6 weeks postpartum.¹ It is a potentially fatal condition marked by organ dysfunction resulting from postpartum infection. The diagnosis is established when a woman presents with at least 2 clinical signs, including pelvic pain, fever (oral temperature ≥ 38.5 °C), abnormal or foul-smelling vaginal discharge, or delayed uterine involution within 6 weeks after delivery.²

Despite a 40% decline in maternal mortality, from 727 to 442 deaths per 100 000 live births between 2000 and 2023, the region still accounts for 70% of global maternal deaths. Each year, an estimated 178 000 mothers and 1 million newborns die in the African region; many of these are preventable causes.³ During childbirth, puerperal sepsis is the leading cause of maternal morbidity and mortality.^4,5 The World Health Organization (WHO) estimated that ∼350 000 maternal deaths occur during labor and childbirth, 10% to 15% of which are associated with puerperal sepsis.⁶ Puerperal sepsis causes at least 75 000 maternal deaths every year. It mostly occurs in low-income countries, with a distribution of 11.6% in Asia, 9.7% in Africa, and 7.7% in Latin America and the Caribbean, compared to 2.1% in developed countries.^5,7 Approximately 540 of the 808 daily maternal deaths occurred in sub-Saharan Africa, compared with 225 in high-income countries.⁸ For this reason, low- and middle-income countries are disproportionately affected by puerperal sepsis, particularly among vulnerable populations.⁹ Thus, the evidence above suggests that maternal mortality due to complications after childbirth in developing countries has become a pressing and significant public health issue.

Complications of puerperal sepsis are life-threatening conditions resulting from organ dysfunction, infection during childbirth, post abortion, or the postpartum period (within 4 weeks after delivery).⁷ Poor hygiene, undetected or poorly managed maternal infections, are leading to puerperal sepsis, death, chronic pelvic inflammatory disease, and infertility or disability for the mother, as well as an increased likelihood of early neonatal infection and adverse outcomes. These chronic complications are major public health issues because they contribute to extending hospital stays, long-term disability, increased resistance of microorganisms to antimicrobials, substantial financial burdens on health systems and families, and death.^10,11 For these public health problems, comprehensive evidences are very important for community-based management.¹² To improve maternal and fetal outcomes, African countries have introduced strategies such as promoting facility-based childbirth with skilled healthcare providers, ensuring access to emergency obstetric and newborn care, strengthening referral systems, and providing postpartum counseling on complications.¹³ However, puerperal sepsis remains difficult to detect early, requiring a high index of suspicion and timely self-care measures.¹³ Despite these efforts, we have not observed significant improvements in maternal or fetal health outcomes.¹⁴ The self-care practices of postpartum mothers for the prevention of puerperal sepsis significantly reduce maternal and neonatal mortality.¹⁵

To date, there have been many primary studies conducted on the prevalence of self-care practices for puerperal sepsis prevention in Africa. However, these primary studies have revealed inconsistent findings, with prevalence rates ranging from 11.1%¹⁴ to 73.9%,¹⁶ and varying degrees of quality scores. According to primary studies on the prevalence of self-care on puerperal sepsis prevention practices and associated factors, such as childbearing age, education level, residence, ignorance, parity, awareness of puerperal sepsis prevention, and antenatal care (ANC) contact status were identified as factors of puerperal sepsis.^17,18 Although some primary studies have been conducted on self-care prevention practices and related factors, the findings have been inconsistent, making it difficult to generalize their results across Africa. Therefore, this systematic review aimed to evaluate the overall self-care prevention practices and their associated factors among postpartum mothers. I hope our findings will help to identify relevant gaps and contribute to improving self-care practices to prevent complications of puerperal sepsis and encourage early self-reporting about the condition. Additionally, determining the pooled prevalence and associated factors will inform the development of effective preventive strategies and guide management of puerperal sepsis-related complications in the African context.

Methods

Study Selection

This systematic review and metaanalysis were registered, conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) checklist¹⁹ (File S1 in the Supplemental Material). The protocol was registered with the PROSPERO database under the number CRD420251042794.

Search Strategy and Review Process

Studies about self-care practices for the prevention of puerperal sepsis and its associated factors were systematically searched in the Web of Science, PubMed, Science Direct, African Journal Online databases, and Google Scholar from December 10, 2023 to January 15, 2024. Additional manual searches from university repositories and Google websites to gather additional data. We used the following keywords during our search: ((Self-practice) OR (prevention puerperal sepsis) OR (prevalence) OR (practice puerperal sepsis) OR (puerperal infection prevention) OR (self-reported practice) OR (self-puerperal infection prevention) AND (associated factors)) OR (determinants)) OR (predictors) AND (postpartum mothers) OR (postnatal) AND (Africa) OR (African women) (Table 1).

Table 1.

Framework for Determining the Eligibility of Studies Populatin, Intervention, Comparison, Outcome, and Time Fram (PICOT).

Criteria	Description
Population	Postpartum mothers
Intervention	Self-care practice
Comparison	Not applicable in this review
Outcome	Prevention of puerperal sepsis
Study area/contest	African countries

The literature search targeted studies on puerperal sepsis prevention and associated factors among postpartum mothers in Africa²⁰ (File S2 in the Supplemental Material). Duplicate records from each database were exported to EndNote ×7 citation manager and removed. Any disagreements were resolved through discussion and consensus or, if needed, by involving all investigators. After duplicates were removed, titles and abstracts of the remaining records were screened. Reference lists of retrieved articles were also reviewed to identify additional relevant studies.

Inclusion and Exclusion Criteria

This review included original research studies (community and facility-based) reporting on the practice of preventing puerperal sepsis and associated factors.

Observational studies with no restrictions on publication year were considered. However, studies published between 2018 and 2023 were considered, with no restriction on publication year, but only studies in English were included. Both published and unpublished articles were eligible. Studies were excluded if they did not clearly report the practice of preventing puerperal sepsis and associated factors in African countries (Table 2). Studies that were not freely accessible, as well as case series, letters, comments, and those that did not report the outcome variable (self-care practice) were excluded. In addition, studies without full texts or clear research objectives, including editorials, reviews, abstracts, and commentaries, were also excluded.

Table 2.

Summary of Studies Included in the Systematic Review and Meta-Analysis of Self-Care Practices and Associated Factors of Puerperal Sepsis Prevention Among Postnatal Mothers in Africa, 2024.

Authors	Pub year	Country	Study design	Study population	Sample size	Participants	Events	Sampling techniques	Prevalence (%)	Quality score
Bishaw et al²¹	2022	Ethiopia	CSS	Postpartum mother	404	390	159	SYRS	40.8	High
Mengistu et al²²	2023	Ethiopia	CSS	Postpartum mother	417	411	187	SRS	45.6	High
Amin et al²³	2018	Ethiopia	CCS	Postpartum mother	600	600	233	SYRS	38.9	High
Fattah et al²⁴	2019	Egypt	CSS	Postpartum mother	120	120	54	Purposive sampling	45.0	High
Tuglo²⁵	2018	Ghana	CSS	Postpartum mother	80	80	5	Purposive sampling	6.0	High
Namuwogne²⁶	2019	Kenya	CSS	Postpartum mother	371	371	274	SRS	73.9	High
Sobhi et al²⁷	2022	Egypt	CSS	Postpartum mother	87	87	22	Purposive sampling	25.5	Medium
Nchimbi et al¹⁴	2022	Tanzania	CSS	postpartum mother	353	343	39	Purposive sampling	11.4	Medium
Allan²⁸	2023	Uganda	CSS	Postpartum mother	49	49	27	Purposive sampling	55.1	Medium
Demisse et al²⁹	2019	Ethiopia	CCS	Postpartum mother	284	280	40	Purposive sampling	14.3	High
Emmanuel³⁰	2023	Uganda	CCS	Postpartum mother	96	73	40	Purposive sampling	55	Medium
Beraki et al³¹	2020	Eritrea	CSS	Postpartum mother	334	250	60	Purposive sampling	24.9	Low
Kamlesh³²	2019	Ghana	CSS	Postpartum mother	659	612	132	SYRS	21.6	Medium
Ghada et al¹⁶	2023	Egypt	Qesd	Postpartum mother	120	120	77	Purposive sampling	64.1	High
Al-Qbelat et al³³	2022	Egypt	Qesd	Postpartum mother	50	50	33	Purposive sampling	65	Medium
Aylate et al³⁴	2023	Ethiopia	CSS	Postpartum mother	422	419	140	SYRS	33.4	High
Allan et al²⁸	2023	Ethiopia	CCS	Postpartum mother	330	330	50	SRS	14.24	High

Note: Qesd, quasi-experimental study design; CSS, cross-sectional study; CCS, case-control study; SYRS, systematic random sampling; SRS, simple random sampling.

Outcome of Interest

The study's outcome variable was self-care practices for preventing puerperal sepsis among postpartum mothers in African countries. Those who scored 5 or higher on the self-care practices assessment questions were considered to have good self-care practices. Reported self-care practices for preventing puerperal sepsis emphasize hygienic measures such as handwashing, maintaining perineal hygiene, changing sanitary pads frequently, engaging in postpartum exercise, preventing wound infections, and being aware of the early signs of puerperal sepsis.

Quality Assessment

The quality of each article was assessed using the Joanna Briggs Institute (JBI) Scale, which was adapted from studies for quality checks.³⁵ The tool contains three main parts. The first part of the tool has five stars and assesses the methodological quality of each study (ie, sampling technique, sample size, response rate, and ascertainment of the risk factor or exposure). The second part of the tool assesses the comparability of the study with a possibility of two stars. The last component of the instrument measures the outcomes and statistical tests of the primary study with a possibility of 3 stars. Finally, the quality assessment tool has a score of 10 items, with a maximum score of 10 and a minimum score of 0. The quality of the primary studies was categorized as low quality (0-5), moderate quality (5-6), and high quality (≥7) (File S3 in the Supplemental Material). Moreover, quality assurance checks were performed by 2 authors (WCT and GMA). Controversies related to the articles were resolved by discussion among all the authors.

Publication Bias and Heterogeneity

Heterogeneity across studies was assessed using Cochran's Q statistic and the I-squared (I²) metric, interpreted as follows: 0% to 25% indicating low or unimportant heterogeneity, 25% to 50% moderate heterogeneity, 50% to 75% substantial heterogeneity, and 75% to 100% considerable heterogeneity.³⁶ Publication bias was evaluated through visual inspection of funnel plots, as well as Begg's and Egger's statistical tests, with a P-value below .05 considered indicative of bias. To assess the robustness of the pooled estimate, a leave-one-out sensitivity analysis was conducted, in which each study was sequentially removed to evaluate its influence on the overall prevalence estimate, assuming no subgroup differences. Additionally, subgroup analysis was conducted based on sampling techniques.³⁷

Data Processing and Analysis

Standardized data extraction was conducted by 2 authors using a structured Microsoft Excel template, followed by joint discussion to resolve any discrepancies. The extracted variables included author names, publication year, country, study setting, sample size, study population, sampling technique, study design, prevalence estimates, and reported risk factors. A random-effects model was applied to synthesize outcome data from the eligible studies. The pooled prevalence was presented with corresponding 95% confidence intervals. All statistical analyses were carried out using STATA Version 11.

Potential sources of heterogeneity were explored using subgroup analyses based on sampling techniques, which indicated that variations in effect estimates were partly attributable to differences in sampling methods. Additional subgroup analysis was performed to assess the influence of individual studies on the overall pooled estimate. Publication bias was examined using funnel plots and Egger's test, with statistical significance set at P < .05. Furthermore, sensitivity analysis was conducted to determine the robustness of the pooled prevalence by evaluating the impact of each study on the combined estimate.

Results

Standard Excel data were extracted from 17 primary studies conducted in African countries. The initial search revealed a total of 74 569 articles, which were subsequently imported into citation manager software (EndNote × 7.0). The studies were located across various databases, including PubMed (19 967), Cochrane Library (1601), Web of Science (786), Science Direct (9027), Google Scholar (37 100), Wiley Online Library (1216), and African Journal Online (2774), complemented by manual searches from the university repository (2098). A total of 50 310 duplicate studies were identified and removed. After a thorough review of the remaining articles based on predefined criteria, seventeen articles were selected for the final analysis (Figure 1).

Figure 1.

Flowchart for systematic review and metaanalysis.

Description of the Studies

A total of 17 studies comprising 4777 participants and 4585 study participants were included in this review, yielding an overall response rate of 95.28%. All 17 studies contributed to estimating the prevalence of self-care practices for preventing puerperal sepsis among postpartum mothers. Regarding study design, 11 studies (64.7%) employed a cross-sectional approach, 12 (70.5%) were analytical, and 5 (25.5%) were descriptive. Quality assessment using the JBI Scale indicated that more than half of the studies (53.0%) were of high quality. The prevalence of self-care practices was reported across several African countries: Six studies (35.3%) were conducted in Ethiopia and 4 (23.5%) in Egypt, as presented in Table 2.

Prevalence of Self-Care Practices for Preventing Puerperal Sepsis

The current metaanalysis revealed that the pooled prevalence of self-care practices for preventing puerperal sepsis among postpartum mothers was 36.09% (95% CI: 26.35, 45.82), I² = 97.6%, P < .001 (Figure 2).

Figure 2.

Forest plot of the pooled prevalence of self-care puerperal sepsis prevention practice among postpartum women.

Subgroup Analysis

To explore the origin of heterogeneity across the included articles, subgroup analysis was conducted on 4 characteristics of the studies, considering study year, study design, sample size, and sampling technique. Regarding the study conducted sampling technique category, study participants selected by simple random sampling techniques resulted in a slightly higher pooled prevalence of self-care practices, which was observed in simple random sampling techniques 50.86% (95% CI: 28.15, 73.56), I² = 96.3%, P < .001. Similarly, based on the study design category, the high heterogeneity among study participants selected by a quasi-experimental study design 64.55 (58.77, 70.32), I² = 0.0%, P = .879. Moreover, to assess the level of heterogeneity by categorizing by study year, study category results showed that a slightly lower pooled prevalence of self-care practices was observed in studies conducted before 2021 (Table 3).

Table 3.

Sub-Group Analyses of the Pooled Self-Care Puerperal Sepsis Prevention Among Postpartum Mothers in Africa.

Variables	Subgroup	Number of studies	Sample size	Prevalence (95% CI)	Heterogeneity across the studies
Study year	<2021	6	2368	33.27 (18.02, 48.53)	I² = 97.1%	P<.001
Study year	≥2021	11	2408	38.55 (26.66, 50.44)	I² = 97.2%	P<.001
Study design	Cross-sectional study	10	2962	36.64 (25.11, 48.17)	I² = 96.8%	P < .001
	Case control study	5	1644	25.68 (13.32, 38.05)	I² = 95.3%	P < .001
	Quasi-experimental study	2	170	64.55 (58.77, 70.32)	I² = 0.0%	P = .879
Sampling techniques	Systematic random sampling	4	1993	24.25 (14.01, 34.48)	I² = 91.2%	P < .001
	Simple random sampling	3	1210	50.86 (28.15, 73.56)	I² = 96.3%	P < .001
	Purposive sampling	10	1574	37.43 (24.61, 50.24)	I² = 97.5%	P < .001
Sample size	<334	8	1217	38.05 (22.59, 53.52)	I² = 98.3%	P<.001
Sample size	≥334	9	3560	33.90 (21.54, 46.25)	I² = 96.6%	P<.001

Sensitivity Analysis

The authors conducted a sensitivity analysis to identify the potential source of heterogeneity. On the basis of the results of a random-effects model, no single study affected the overall prevalence of self-care practices among postpartum mothers in Africa (Figure 3).

Figure 3.

Funnel plot assessed for publication bias in 17 studies.

Metaregression

To handle heterogeneity, the effects of study participants, sample size, and year of the study on heterogeneity among the studies via a metaregression model were assessed. However, there was no significant prediction of heterogeneity between the effect size and the assessed variables (sample sizes, study participants, years of the study, and quality of included papers) (Table 4). In the adjusted model, the sample sizes, study participants, and years of the study did not indicate heterogeneity (P < 0.1) in the effect size, which is equivalent to the pooled proportion.

Table 4.

Metaregression.

Log odds	Coef.	Std. Err.	t	P>\|t\|	[95% Conf., Interval]
Participants	0.0083074	0.1481027	0.06	0.956	−0.3116491, 0.328264
Pub year	0.0392146	1.674578	0.02	0.982	−3.57849, 3.65692
Sample size	−0.0081011	0.1431929	−0.06	0.956	−0.3174506, 0.3012484
_cons	−79.17586	3387.214	−0.02	0.982	−7396.806, 7238.455
High quality	0.0083061	0.1481033	0.07	0.956	−0.4116441, 0.329264
Medium quality	0.0362144	1.674348	0.03	0.992	−2.57859, 3.64693
Low quality	−0.0071012	0.1441349	−0.07	0.21	−0.3175501, 0.4012485
_cons	−89.17586	3487.214	−0.03	0.982	−8396.806, 8238.555

Publication Bias

The publication biases of pooled self-care puerperal sepsis prevention practices among postpartum mothers were assessed using Egger's regression test and funnel plots. Egger's regression test revealed that there was publication bias across studies (P < .001) (Table 5). The funnel plot results also revealed an asymmetric shape, indicating the presence of publishing bias (Figure 4). Nonparametric trim and fill analyses were done for self-care puerperal sepsis prevention practices done among postpartum mothers. However, there were no included studies, and the resulting pooled self-care puerperal sepsis prevention practices among postpartum mothers were 40.53% (95% CI: 30.60, 50.26), I² = 75.94, P < .001 (Figure 5).

Figure 4.

Output of sensitivity analysis of 17 studies.

Figure 5.

Trim and filled analysis.

Table 5.

Egger's Regression.

Egger's test
Std_Eff	Coef.	Std. Err.	t	P > t	[95% Conf., Interval]
Slope	196.6019	0.0609103	3227.73	0.000	196.4721, 196.7317
Bias	−19.65734	0.0061989	−3171.09	0.000	−19.67056, −19.64413

Factors Associated With Self-Care Prevention of Puerperal Sepsis

Based on this review, urban residence, mothers’ educational status, and level of knowledge, and mothers who had more than ANC contacts were found to be significant associated factors with the prevalence of self-care puerperal sepsis prevention practices among postpartum mothers. According to these associations, 5 studies^{21,22,25,27,29} showed that urban dwellers have a significant association with self-care prevention of puerperal sepsis. Postpartum mothers who lived in urban areas were 3.23 times (AOR: 3.23; 95% CI: 1.86, 5.63) more likely to practice self-care prevention for puerperal sepsis than those who lived in rural areas. A random effect model was used in this metaanalysis, as the included studies were characterized by low heterogeneity (I² = 25.84%, P < .001).

The pooled odds ratio estimates of self-care for puerperal sepsis prevention practices in 6 studies^{21,22,26,27,29,32} showed that postpartum mothers with a tertiary education status or above were approximately (AOR: 2.28, 95% CI: 1.11, 4.67) times more likely to practice self-care for puerperal sepsis prevention than postpartum mothers with a tertiary education status or below. In this metaanalysis, the included studies exhibited heterogeneity (I² = 83.8%, P < .001). Thus, we used a random effect model.

In this metaanalysis, the pooled odds ratio (AOR) for self-care puerperal sepsis prevention practices in 5 studies^{21,22,24,26,38} showed that postpartum mothers who had good knowledge of puerperal sepsis prevention practices and who experienced health problems during the postpartum period were 2.45 times more likely to have self-care puerperal sepsis prevention practices than postpartum mothers who had poor knowledge about self-care puerperal sepsis prevention practices (AOR:2.45, 95% CI:1.09, 5.50). In this metaanalysis, there was heterogeneity among the included studies (I² = 92.2%, P < .001). Thus, we used a random effect model.

The number of ANC follow-up visits was a significant factor in puerperal sepsis prevention. According to the present analysis, the pooled odds ratios of self-care puerperal sepsis prevention practices in the 5^{17,28,32,34,39} included studies were ∼3.75 times greater for self-care puerperal sepsis prevention practices than for previous pregnant women with ≥ 4 ANC contacts (AOR: 3.75, 95% CI: 2.23, 6.31). In this metaanalysis, the included studies exhibited heterogeneity (I² = 74.7%, P = .003). Thus, we also used a random effect model (Figure 6).

Figure 6.

Forest plot showing the pooled odds ratio of the different factors associated with self-care puerperal sepsis prevention practice among postpartum mothers in Africa.

Discussion

In this systematic review and metaanalysis, we systematically reviewed the pooled prevalence of self-care puerperal sepsis prevention practices among postpartum mothers and identified 17 study articles from 8 African countries with a total of 4585 study participants. According to this review, the pooled prevalence of self-care puerperal sepsis prevention practices among postpartum mothers in Africa was 36.09% (95% CI: 26.35, 45.82). This self-care practice regarding the prevention of puerperal sepsis among postnatal mothers was in line with studies conducted in India, ranging from 26.36% to 45.3%.^40,41 However, this pooled prevalence was lower than that reported in studies conducted in Bangladesh (78%),¹⁵ Malaysia (76%),⁴² and India (66.8%).⁴³ The low level of self-care practice for this review could be attributed to many factors, such as low knowledge at the community and individual levels regarding the cause of puerperal sepsis and its preventive measures.

The health system capacity and cultural practices in Bangladesh and Malaysia may differ significantly from those in African countries, which could affect the applicability of findings across these settings. For example, Bangladesh⁴⁴ and Malaysia⁴⁵ have relatively stronger health infrastructures, wider health insurance coverage, and higher facility-based delivery rates compared to many African countries, where limited resources and traditional birth practices remain more common.⁴⁶

Additionally, healthcare providers may pay less attention to instructing postnatal mothers about self-care for the prevention of puerperal sepsis. Another difference could be the variation in methodology, study area, institutional delivery coverage, and quality of maternity services. For example, in a study in India, the study participants were both postpartum women and healthcare providers. They may have high awareness about sepsis prevention. The good quality of maternity services and the high rate of institutional delivery coverage decrease the incidence of puerperal sepsis.⁴⁷ In addition, self-reports of postpartum women at the individual level might prevent puerperal sepsis.

This metaanalysis revealed that postpartum mothers who lived in urban areas were more likely to use self-care puerperal sepsis prevention practices than those who lived in rural areas. This finding was supported by a systematic study.²³ This could be because people living in urban areas have access to more healthcare-related advice from different media than people living in rural settings. This positive association is supported by a similar study in Asmara.³¹ Special attention should be given to this identified gap in self-care practice regarding puerperal sepsis prevention among rural postpartum mothers. Furthermore, community-based education campaigns should be implemented to raise awareness about the importance of postnatal follow-up and the prevention of puerperal sepsis through proper hygiene practices after childbirth.

This study revealed that self-care practices for preventing sepsis in puerperal patients were associated with education status. The study revealed that postnatal women who attended tertiary and higher education were more likely to self-report preventive practices against puerperal sepsis than their counterparts. This finding is supported by previous studies.^17,41 This may be because postpartum mothers who are more educated are better able to access and utilize maternal health care services, which enhances their health-seeking behavior and enables them to more effectively practice self-care measures for the prevention of puerperal sepsis. Postpartum individuals may not have received adequate education, which can expose them to health literacy challenges and difficulties in easily understanding postpartum infections. Moreover, universal education enhances the efficacy of puerperal sepsis prevention practices.²³ Five studies showed that self-care practices were positively associated with puerperal sepsis prevention practices. The study revealed that postnatal women who had adequate knowledge were more likely to have preventive measures against puerperal sepsis than were those who had poor knowledge, such as postpartum mothers. This could be because postnatal women have adequate knowledge on how to prevent and self-report signs and symptoms of puerperal sepsis complications early. Evidence from India indicates that achieving meaningful reductions in maternal mortality related to puerperal sepsis requires maternal healthcare providers to prioritize knowledge transfer among pregnant and postpartum women. This is because improved knowledge and preventive practices regarding infection in the early postpartum period reinforce each other and lead to better maternal health outcomes.⁴⁸ Another study in China suggested that knowledge of health practices can be improved in postnatal women during the postnatal period to prevent puerperal sepsis.⁴⁹

Finally, the current review showed that there was an increase in the prevalence of self-care for puerperal sepsis prevention practices resulting from having more than 4 ANC contacts. Postnatal women who had more than 4 ANC contacts had a significantly greater chance of having good self-care and puerperal sepsis prevention practices than those with fewer than four ANC contacts. This positive correlation was supported by various studies.^38,50 The reason for this similarity may be that the attendance of ANC for more than 4 contacts could be beneficial for mothers to receive more information regarding the prevention of puerperal sepsis. Health information and health promotion regarding the prevention of puerperal sepsis during ANC from healthcare providers, postpartum women's knowledge, and reported self-care practices for the prevention of puerperal sepsis.⁴⁹ More ANC services provide critical health education, timely screening, and prophylactic interventions, which are essential for infection prevention.

Strengths and Limitations

To the best of our knowledge, this review is the first to synthesize data from 17 primary studies and provide current evidence on self-care practices for the prevention of puerperal sepsis in Africa. However, the review had several limitations. It was restricted to English-language, full-text articles, and most included studies were cross-sectional, limiting causal inference. Only 8 African countries were represented, which may have affected the pooled prevalence estimates. Moreover, over 25% of the studies relied solely on descriptive statistics without analytical assessment of determinants. Therefore, qualitative research is needed to enhance comparability across settings and clarify the impact of risk factors and protective interventions.

Implications for Public Health and Policy

The findings from our review have significant implications for public health and policy in Africa. The low rate of self-care practices for preventing puerperal sepsis emphasizes the need to incorporate health extension services into maternal healthcare programs. African healthcare systems should prioritize promoting self-care practices for puerperal sepsis prevention during postnatal visits, ensuring that new mothers have access to the support and care they need. The current guidelines should be revised to more effectively integrate the health extension program into maternal and postpartum care services.

Conclusion and Recommendation

Prevention of puerperal sepsis by self-care practice was limited in African postpartum women. Being highly educated, having adequate levels of knowledge, and having more than 4 ANC contacts are significantly associated with self-care practices for the prevention of puerperal sepsis among postpartum mothers in African countries. Ministries of Health should develop and disseminate standardized, pictogram-based educational materials on puerperal sepsis prevention for use during antenatal and postnatal care visits, with a focus on community health workers serving rural populations. Self-care practices for preventing puerperal sepsis can be improved through effective health education during the immediate postpartum period, as well as by addressing the rural population during antenatal and postnatal care visits to encourage self-reporting on the prevention of postpartum complications, including puerperal sepsis. Therefore, regular follow-up and intensive health promotion during antenatal and postpartum care for patients at risk of puerperal sepsis is urgently needed, especially for postnatal women with low levels of education in rural areas.

Supplemental Material

sj-pdf-1-jia-10.1177_23259582261447166 - Supplemental material for Self-Care Practices for Puerperal Sepsis Prevention and Associated Factors Among Postnatal Women in Africa: A Systematic Review and Meta-Analysis

Supplemental material, sj-pdf-1-jia-10.1177_23259582261447166 for Self-Care Practices for Puerperal Sepsis Prevention and Associated Factors Among Postnatal Women in Africa: A Systematic Review and Meta-Analysis by Agerie Mengistie Zeleke, Worku Chekol Tassew and Girum Meseret Ayenew, Yeshiwas Ayale Ferede, Jember Ayelgne Beyene in Journal of the International Association of Providers of AIDS Care (JIAPAC)

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Footnotes

Acknowledgments

The authors would like to thank the authors of the included primary studies, which were used as sources of information to conduct this systematic review and metaanalysis.

ORCID iDs

Agerie Mengistie Zeleke

Yeshiwas Ayale Ferede

Jember Ayelgne Beyene

Author Contributions

AMZ and WCT developed the protocol and were involved in the study design and selection. JAB and YAG were involved in the data extraction. AMZ, WCT, GMA, and YAF were involved in the statistical analysis, development of the initial drafts of the manuscript, quality assessment, statistical analysis, and revision of the manuscript. WCT and AMZ prepared the final draft of the manuscript. All the authors have read and approved the final draft of the manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets generated and/or analyzed in this study are available from the corresponding author on reasonable request.

Prospero Registration

The protocol was registered with the PROSPERO database under the number CRD420251042794.

Supplemental Material

Supplemental material for this article is available online.

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