A C TA Obstetricia et Gynecologica

AOGS S H O R T RE S E A R CH RE P OR T

Prevalence of postpartum infections: a population-based

observational study
DANIEL AXELSSON1,2 & MARIE BLOMBERG1
1
Department of Obstetrics and Gynecology and Department of Clinical and Experimental Medicine, Linko€ping University,
Linko€ping, and 2Ryhov County Hospital, Jo€nko€ping, Sweden

Key words Abstract

Infections, postpartum, mastitis, urinary tract
infection, endometritis, wound infection
Correspondence
Daniel Axelsson, Department of Obstetrics
and Gynecology, Ryhov County Hospital, 581
€nko
85 Jo €ping, Sweden.
E-mail: daniel.axelsson@lj.se
Conflict of interest
The authors have stated explicitly that there
are no conflicts of interest in connection with
this article.
Please cite this article as: Axelsson D,
Blomberg M. Prevalence of postpartum
infections: a population-based observational
study. Acta Obstet Gynecol Scand 2014; 93:
1065–1068.
We investigated the prevalence of postpartum infections among women giving
birth during 1 year in a population-based observational/questionnaire study at
seven hospitals in the southeast region of Sweden. Of the women >99%
(n = 11 124) received a questionnaire to inquire if they had endometritis, masti-
tis, or wound, urinary tract or any other infection within 2 months postpartum
and whether they received antibiotics for this. Prevalence rates for infections and
antibiotic treatment were estimated. The response rate was 60.1%. At least one
infectious episode was reported by 10.3% of the women and 7.5% had received
antibiotics. The prevalence for infections with and without antibiotics were,
respectively, mastitis 4.7% and 2.9%, urinary tract infection 3.0% and 2.4%,
endometritis 2.0% and 1.7%, wound infection 1.8% and 1.2%. There was no
inter-county difference in infection prevalence. Clinical postpartum infections in
a high-resource setting are relatively common.
Abbreviation: UTI, urinary tract infection.

Received: 9 September 2013

Accepted: 27 June 2014

DOI: 10.1111/aogs.12455

To determine the prevalence of postpartum infections

Introduction
Puerperal infection is a leading cause of maternal
mortality and morbidity (1). Mortality from postpartum
infections, however, has continuously decreased in
middle- or high-resource countries (2). Nevertheless, 16%
of maternal mortality in the USA was due to infections as
late as in the latter half of the twentieth century (3).
Postpartum infections affect 5–24% of women (1,4). The
most common postpartum infections are endometritis,
urinary tract infection (UTI), wound infection and
mastitis (1). The only available Swedish prevalence data,
from the early 1990s, showed a prevalence of postpartum
endometritis of 2.5% (5). Studies have also shown
postpartum infection to be one of the most common
causes of prolonged hospital stay and readmission after
childbirth (6–8).
we conducted a population-based observational and ques-
tionnaire study among women giving birth in the south-
east region of Sweden during 1 year.
Material and methods
The southeast region of Sweden has three counties with
seven hospitals. Delivery wards in the region use similar
guidelines and routines for pregnancy and postpartum
care and almost all women give birth in a hospital. Peni-
cillin G is given intrapartum to women at risk of infec-
tion with Group B Streptococci. Prophylactic antibiotics
(usually cefuroxime 1.5 g) are given after cord clamping
to women undergoing emergency cesarean section.
The hospitals in the region used a common computer-
ized patient record system (Obstetrix
, Siemens, www.

ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 1065–1068 1065
Prevalence of postpartum infections D. Axelsson & M. Blomberg

siemens.com) for registering all women attending ante-, A total of 690 women (10.3%) reported 770 infections.
peri- and postnatal care. From this system, all women The most common infection was mastitis, followed by
who gave birth in the region during the period 1 April UTI. Postpartum infection prevalence with and without
2009 to 31 March 2010 (one center 1 September 2009 to antibiotic treatment are presented in Figure 1. Wound
31 August 2010) were identified. Maternal characteristics infection was reported by 56 women (1.0%) after vaginal
and obstetric outcome were obtained from the computer- delivery and by 64 women (6.5%) after cesarean section.
ized patient record system. Eight weeks postpartum each Wound infection after vaginal birth was treated with anti-
mother received by mail a validated questionnaire to biotics in 61% of cases and in 72% of cases after cesarean
report if she had experienced infection in the urinary section. Women with endometritis were most likely to
tract, uterus, wound or breasts, and if so, to specify if she receive antibiotics, whereas women with mastitis were
had received antibiotics. She was also asked to report any least likely.
other infection during this period and if so, what type. A A total of 55 women (0.8%) reported other infections,
pre-paid envelope was provided. In 2008, a pilot study i.e. upper respiratory tract and fungal infection, each
with a similar design was conducted, involving all women 0.3%. Two women reported sepsis, two women pneumo-
who gave birth in the region during 1 month. The nia and other infections (folliculitis, gastroenteritis and
response rate at that time without a reminder was 78%, erysipelas) were reported by one or two women each. The
which was the reason for not using reminders in this response rates and the prevalence of infections by coun-
study. The replies were manually recorded in a database ties are presented in Table 2. No difference was found
on the regional delivery wards, together with the national between the counties concerning prevalence of infections.
identity number for each woman, and collected to a cen- Prevalence of infections at the regional tertiary hospital
tral database. SAS
software v. 9.2 (SAS Institute, Cary, was also compared with the prevalence of infections at all
NC, USA) was used for statistical analysis (chi-squared
test and Student’s t-test).
The regional Ethical Review Board, University of 5.0%
No antibiotics
Link€oping, approved the study (no. M44-09 2009-05-12). 4.5%
Antibiotics
All participants gave informed consent. 4.0%
1.8%
3.5%
Results 3.0%
0.6%
2.5%
In all, 11 124 women were sent the questionnaire
€
(Osterg€otland county 4947 women, J€ onk€oping 3838, Kal-
2.0%
0.3%
1.5% 2.9% 0.6%
mar 2339 women) and 6682 (60.1%) agreed to partici- 2.4%
1.0%
pate. Comparative data about responders and 1.7%
0.5% 1.2%
nonresponders are presented in Table 1. There was a sig-
0.0%
nificant difference between responders and nonresponders Mastitis UTI Endometritis Wound infection
concerning age, body mass index and parity. No signifi-
cant difference was found concerning blood loss, mode of Figure 1. Prevalence of postpartum infections in southeast Sweden.
delivery and induction of labor. UTI, urinary tract infection.

Table 1. Maternal characteristics of responders and nonresponders in a population-based study on prevalence of postpartum infections.

Responders (n = 6682) Nonresponders (n = 4442)

Maternal characteristics Mean (95% CI) Mean (95% CI) p-value

Age (years) 30.8 (30.7–30.9) 29.2 (29.0–29.4) <0.05

Body mass index (kg/m2) 24.9 (24.8–25.0) 25.2 (25.0–25.3) <0.05
Parity 0.81 (0.79–0.83) 0.94 (0.90–0.97) <0.05
Blood loss (mL) 482 (473–492) 474 (463–485) n.s.
Normal vaginal delivery (%) 78.0 78.7 n.s.
Instrumental delivery (%) 7.3 7.4 n.s.
Cesarean section (%) 14.7 13.9 n.s.
Induced labor (%) 12.8 14 n.s.

1066 ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 1065–1068
D. Axelsson & M. Blomberg Prevalence of postpartum infections

Table 2. Response rate and prevalence of infections by county.

Endometritis/ Wound infection/

Mastitis/Antibiotic- UTI/Antibiotic- Antibiotic-treated Antibiotic-treated
Responders treated Mastitis treated UTI Endometritis wound infection

County/Hospital n % n % n % n % n %

€
County of Osterg €tland
o 2992 60.5 126/83 4.2/2.8 96/77 3.2/2.6 66/57 2.2/1.9 63/43 2.1/1.4
€ping
University Hospital, Linko 1635 62.1 62/43 3.8/2.6 57/46 3.5/2.8 47/38 2.9/2.3a 30/20 1.8/1.2
County of Jo€nko
€ping 2393 62.4 117/63 4.9/2.6 60/48 2.5/2.0 41/37 1.7/1.5 41/28 1.7/1.2
County of Kalmar 1297 55.5a 73/48 5.6/3.7) 45/35 3.5/2.7 26/22 2.0/1.7 16/9 1.2/0.7

University Hospital, Linko €ping is the tertiary center in the region. An estimation of differences in response rate and prevalence of the four
infections between counties and between the tertiary center and all counties was performed.
UTI, urinary tract infection.
a
p < 0.05. All other p-values were nonsignificant.

the county hospitals and endometritis occurred signifi-
cantly more often at the tertiary center.
Discussion
One in ten women had at least one infectious episode
within the first 8 weeks postpartum, i.e. primarily masti-
tis, UTI, endometritis or wound infection. Three-quarters
of the women received antibiotic treatment. Mastitis was
the most common infection.
This study has strengths and limitations. Prevalence
rates were estimated from questionnaire replies, which
have a relatively low sensitivity in identifying postpartum
infections (9). With questionnaires it is, however, possible
to detect infections diagnosed after hospital discharge,
which seem in other studies to be the majority of post-
partum infections (4,9–11). Women who acquire an
infection after hospital discharge will be treated in the
outpatient setting and the infections may therefore not be
registered nor easily identified from clinical records.
Women who had an infection may also be more prone to
reply to the questionnaire; therefore the true prevalence
in the population could be lower. In Sweden a prescrip-
tion is needed for antibiotics and a Prescribed Drug Reg-
ister has existed since 2005 (12), but the register does not
contain information about diagnoses or infection sites
nor is it actual proof of purchase or use of the drug. A
strength of the study was that it included reported infec-
tions with or without antibiotic treatment. Wound infec-
tion and mastitis were the two puerperal infections where
antibiotic treatment was most often not applied (33 and
39%, respectively).
We found a higher prevalence of postpartum infections
than previously reported (6,9). Yokoe et al. described a
6% prevalence for the same infections in a questionnaire
study (9), while Hebert et al. found that 3.1% of women
acquired an infection leading to prolonged hospital stay
(>5 days after vaginal birth, >7 days after cesarean sec-
tion) or readmission to hospital (6). In a Danish study
where positive wound or urine cultures and prescription
records were used to identify infections, the prevalence of
antibiotic-treated UTIs and wound infections was 2.7%
(13), compared with 3.6% for the same infections in the
present study. Another Danish study showed a higher,
self-reported prevalence of puerperal infections; for the
same infections as in the present study the occurrence
was almost double or 20% (4). Most of the difference
was attributed to an almost three times as high prevalence
of mastitis and twice as high rate of wound infections,
whereas UTI and endometritis prevalence were similar to
this study. Methods in the Danish study were similar, i.e.
questionnaire-based, with self-reported infections and in
both studies approximately two-thirds of reported infec-
tions were treated with antibiotics.
Regional comparisons of prevalence rates of infections
are important to detect putative differences in local clini-
cal care routines, but no differences were seen between
the counties in the region. It can be difficult to extrapo-
late results for the entire population from a study with
moderate response rates and some maternal characteris-
tics did differ between responders and nonresponders,
but given the uniformity of Swedish society and the lack
of inter-county differences, it is likely that the results
could be valid for the population at large.
Funding
Funding for this study was received from Medical
Research Council of Southeast Sweden.
Acknowledgments
The authors thank the southeast regional obstetric group
for assisting in collecting data, Mats P Nilsson, PhD, for
statistical analysis and Evelina Axelsson, MSc, for assisting
with data compilation.

ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 1065–1068 1067
Prevalence of postpartum infections
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