The golden hour of sepsis: An in-depth analysis of sepsis-related maternal mortality in middle-income country Suriname
The golden hour of sepsis: An in-depth analysis of sepsis-related maternal mortality in middle-income country Suriname
Lachmi R. Kodan 0 1
Kim J. C. Verschueren 1
Humphrey H. H. Kanhai 1
Jos J. M. van Roosmalen 1 2
Kitty W. M. Bloemenkamp 1
Marcus J. Rijken 1
0 Department of Obstetrics and Gynaecology, Academical Hospital Paramaribo (AZP), Paramaribo, Suriname, 2 Department of Obstetrics, Division Women and Baby, Birth Centre, University Medical Center Utrecht, Utrecht, the Netherlands , 3 Julius Global Health , The Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht , Utrecht , The Netherlands , 4 Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands, 5 Anton de Kom University , Paramaribo , Suriname
1 Editor: Laura A. Magee, King's College London , UNITED KINGDOM
2 Athena Institute, VU University Amsterdam , Amsterdam , the Netherlands
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
Funding: The authors received no specific funding
for this work.
Competing interests: The authors have declared
that no competing interests exist.
Sepsis was the main cause of maternal mortality in Suriname, a middle-income country.
Objective of this study was to perform a qualitative analysis of the clinical and management
aspects of sepsis-related maternal deaths with a focus on the `golden hour' principle of
A nationwide reproductive age mortality survey was performed from 2010 to 2014 to identify
and audit all maternal deaths in Suriname. All sepsis-related deaths were reviewed by a
local expert committee to assess socio-demographic characteristics, clinical aspects and
Of all 65 maternal deaths in Suriname 29 (45%) were sepsis-related. These women were
mostly of low socio-economic class (n = 23, 82%), of Maroon ethnicity (n = 14, 48%) and
most deaths occurred postpartum (n = 21, 72%). Underlying causes were pneumonia (n =
14, 48%), wound infections (n = 3, 10%) and endometritis (n = 3, 10%). Bacterial growth
was detected in 10 (50%) of the 20 available blood cultures. None of the women with sepsis
as underlying cause of death received antibiotic treatment within the first hour, although
most women fulfilled the diagnostic criteria of sepsis upon admission. In 27 (93%) of the 29
women from which sufficient information was available, substandard care factors were
identified: delay in monitoring in 16 (59%) women, in diagnosis in 17 (63%) and in treatment in
In Suriname, a middle-income country, maternal mortality could be reduced by improving
early recognition and timely diagnosis of sepsis, vital signs monitoring and immediate
antibiotic infusion (within the golden hour).
Sepsis is a major cause of severe maternal morbidity and mortality, especially in low- and
middleincome countries. Early recognition of sepsis is crucial and sepsis should be treated by
resuscitation with fluids and effective intravenous antibiotics should be given within one hour of the
]. The ªgolden hour of sepsisº stresses the relationship between timely initiation of
antibiotic treatment and outcome: each hour delay in treatment reduces sepsis survival by 7.6%
]. Pregnancy and delivery predispose women to infectious complications due to immunological
and physiological alterations or from tissue damage during delivery. Recognition of sepsis during
pregnancy, delivery and postpartum is difficult because of physiological adaptations to pregnancy,
blood loss and increased maternal activity during labour [
]. WHO recently launched a new
consensus defining maternal sepsis: a life-threatening condition defined as organ dysfunction
resulting from infection during pregnancy, childbirth, post-abortion, or postpartum period [
Although the `golden hour of sepsis' principle is not validated for women with pregnancy
or in the puerperium due to a lack of studies, the principle is assumably even more important
in pregnant, predisposed women where recognition is more difficult.
Globally, maternal sepsis (10%) is the third most frequent cause of direct maternal deaths,
preceded by hemorrhage (27%) and hypertension (14%) [5±7]. In low- and middle-income
countries (LMIC) maternal sepsis is a larger contributor to maternal mortality than in
highincome countries (10.7% vs. 4.7% respectively) [
]. In high-income countries, however,
maternal morbidity and mortality due to sepsis is increasing [
Suriname is an upper middle-income country in South America with a maternal mortality
ratio of approximately 130 per 100.000 live births between 2010 and 2014 [
]. A confidential
enquiry in Suriname in 1991 reported sepsis to be the third most frequent underlying cause of
maternal death (n = 10/64, 16%) [
]. We recently published an increase in maternal deaths
from sepsis, with sepsis as the most frequent cause (n = 17/65, 27%) [
]. This is poorly
understood; therefore an in-depth case analysis was considered necessary.
Classification of maternal deaths into direct (obstetric) and indirect (non-obstetric) causes has
given the impression that direct maternal deaths should receive greater attention than indirect
deaths. However, since the focus is on the reduction of all preventable deaths, division between
direct and indirect maternal deaths can be seen as arbitrary and counterproductive [
]. In this
study, we therefore choose for a more theme-based approach by analysis of all sepsis-related deaths.
Primary objective of this study was to perform a qualitative analysis of the clinical aspects
and management (based on the golden hour principle) of sepsis-related maternal deaths in
Suriname. Secondary objectives were first to describe incidence and characteristics, second to
analyze underlying causes, and third to evaluate quality of care and finally substandard care
identification with audit to improve sepsis prevention, recognition and treatment strategies.
Suriname is multi-ethnical with 541.638 inhabitants and one of the smallest populated
countries in South America, with a density of 3,3 inhabitants per square kilometer. There are
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approximately 10.000 deliveries annually of which most in hospitals led by midwives and
obstetricians (82%) [
]. Women with high-risk pregnancies are referred by the primary
health services, which can take more than two hours, as some rural areas are only accessible by
boat or airplane. Postpartum, women are usually discharged from hospital six hours after an
uncomplicated delivery. They are seen at outpatient clinics or hospitals once, seven days after
discharge. Postnatal care home visits are not done.
In 2015 a reproductive age mortality survey (RAMoS) was performed to identify maternal
deaths in Suriname between 2010 and 2014 [
]. Medical records were collected of
pregnancy related deaths identified by vital registration, or by screening of medical archives of all
hospitals and primary care facilities. An anonymous case summary was made conform the
FIGO-LOGIC MDR clinical summary form tool [
]. A local expert committee consisting of
obstetricians, midwives, internal medicine specialists or anaesthesists reviewed each case
summary. The committee agreed on the underlying causes and classified the cases [
analyse substandard care factors an adapted version of the FIGO-LOGIC MDR Grid analysis
of clinical case management form was used [
]. For this study specifically, medical records
of all maternal deaths related to sepsis, were scrutinized for signs of sepsis, clinical
management, primary sources of infection and causative pathogens. Data were manually entered
into IBM SPSS version 21.0 (Armonk, New York, USA) for analysis. Descriptive statistics
and frequencies were used to describe patient demographics, clinical and pregnancy
characteristics and substandard care factors. Graphs were manually made in IBM SPSS version 21.0
and Microsoft Excel 2016 to demonstrate qualitative information on sepsis diagnosis and
Sepsis-related maternal deaths included deaths with sepsis as the underlying cause, sepsis as
the mode of death and sepsis as a contributing factor. The underlying death cause was defined
as the disease or condition that initiated the chain of events leading to death . The mode of
death was the disease or condition ultimately leading to death . A contributing factor was
defined as a condition existing before or developed during the chain of events leading to death,
that predisposed the woman to death but was not causing death .
Clinical diagnosis of severe maternal sepsis was made by using the UK Obstetric
Surveillance System definition, which is an adapted version of the systemic inflammatory response
syndrome (SIRS) criteria: an assumed or proved infection with at least two of the four criteria
(temperature of > 38ÊC or < 36ÊC, heart rate of > 100 beats per minute, respiratory rate
of > 20 per minute, white blood cell count of > 17 x 109 cells/L or < 4 x 109 cells/L) measured
on two occasions at least four hours apart [
]. Severe sepsis was associated with organ
dysfunction (i.e. cardiovascular, respiratory, renal, coagulation, hepatic, neurological and uterine),
hypoperfusion or hypotension [
]. Organ dysfunction was determined with the WHO
near-miss tool [
]. In depth analysis of the maternal deaths with sepsis as underlying cause
was performed in this study by determining when the first clinical signs of sepsis were
manifested. The `golden hour' principle (intravenous antibiotics given within an hour of severe
sepsis diagnosis) was then evaluated [
Substandard care was defined as care below expected standards in the specific setting the
woman was treated. The local expert committee evaluated substandard care in the absence of
guidelines on sepsis in Suriname. Assessment of delay in receiving care was made by
evaluating vital signs monitoring, diagnosing sepsis and initiation of antibiotic treatment. Other
substandard care factors such as miscommunication, availability and patient-associated factors
were also evaluated.
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The medical ethical review board of the Surinamese Central Committee on Research Involving
Human Subjects and the Ministry of Health of Suriname approved the study [VG 006±15].
Patient's names, hospitals and health care workers information remained confidential. No
informed consent was required as only retrospective anonymized information from medical
records of deceased women was used.
In the previously reported study on maternal mortality in Suriname between 2010 and 2014
sepsis was the most frequent underlying cause of death occurring in 17 of the 65 maternal
]. Of the women who died of other underlying causes, in five sepsis was the mode of
death and in seven women sepsis was contributing to the death. Hence, in total 29 (45%) of the
65 maternal deaths were sepsis-related. (Fig 1) Medical records of two sepsis-related deaths
(classified as indirect deaths with sepsis as underlying cause) were missing, therefore in-depth
analysis of clinical aspects and substandard care was performed in 27 (93%) of sepsis-related
maternal deaths. All the sepsis-related cases defined by the expert committee were also
diagnosed by the clinicians who were in charge of the patients.
In fourteen (48%) of the twenty-nine sepsis-related maternal deaths women were from
maroon ethnicity, of which 13 (93%) had social insurance (insurance paid by the government
for people of low socio-economic status) (Table 1). Death occurred postpartum in 21 women
(72%), mostly within one week (n = 13, 62%). Two of the HIV-positive deceased women also
had sickle cell (type SS) disease. Eighteen women (62%) died in the intensive care or coronary
care unit, while nine (31%) died on the ward where critically ill women could not be
monitored adequately. One woman died in the emergency department and one at home. Caesarean
section was performed in eight (38%) of the 21 postpartum, sepsis-related deaths. All were
elective cesarean sections; in two of these eight women the death was classified as a direct
maternal death (Table 2). In four women a caesarean section was performed because of
preeclampsia, in one case because of fetal distress, one woman had a sickle cell crisis, and two
women were in a critical condition due to heart failure and Shigella sepsis.
Fig 1. Overview of the sepsis-related maternal deaths between 2010 and 2014 in Suriname.
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PLOS ONE | https://doi.org/10.1371/journal.pone.0200281
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Sepsis deaths n = 29 (%)
Antenatal care starting from gestation of 16 weeks. (n = 27)
# Perinatal death is death of fetus with a gestation of more than 22 weeks or 500 grams
Classification and causes
a. Sepsis as the underlying cause. Four women with sepsis as underlying cause were
classified as direct maternal deaths (Table 2). Underlying causes were endometritis in three
women and wound infection in one woman. All women had term or near-term pregnancies
and died within the first week postpartum. They had ruptured membranes less than 12 hours
before delivery and none of the neonates died or showed signs of infection. The remaining 13
deaths were classified as indirect maternal deaths: pneumonia (n = 7, 54%), meningitis (n = 2),
gastro-enteritis (n = 2), urosepsis (n = 1) and HIV therapy-induced hepatitis (n = 1).
b. Sepsis as the mode of death. These five cases included death from 1) a bowel
perforation following a mechanically induced abortion; 2) a central venous line sepsis in a woman in
the ICU with bleeding from coagulation disorders following fetal death syndrome; 3) a
craniotomy wound infection in a hypertensive woman with intracranial bleeding and eclampsia; 4)
severe sepsis following multi-organ failure after iatrogenic hypotension due to overdose of
antihypertensive medication in severe pre-eclampsia and 5) endocarditis in a woman with
aortic valve prosthesis.
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c. Sepsis as a contributing factor. In seven cases sepsis was a contributing factor;
underlying causes were severe pre-eclampsia / eclampsia (n = 4), diabetic kidney failure with an
infected diabetic foot and osteomyelitis (n = 1), heart failure in a woman with mitral valve
prostheses and endocarditis (n = 1) and one case where sepsis contributed to the death but
with the cause remaining unclear.
The main cause of infection was pneumonia, which affected 14 women (48%), followed by
wound infections (n = 3, 10%) and endometritis (n = 3, 10%). Blood, urine and/or sputum
cultures or vaginal swabs were obtained in 23 cases (85%). No culture was done in four cases
because of temperature below 38 degrees (n = 2), very rapid deterioration of the condition of
the patient (n = 1) and loss of blood sample before reaching the laboratory (n = 1). Results of
the cultures were available in 20 cases and not traceable in the remaining three cases. Either
one of the cultures were positive in 15 cases (75%). Blood culture showed growth of pathogens
in 10 cases (50%) (Table 3).
Fig 2 demonstrates the number of cases per dysfunctioning organ system. At least two organ
dysfunctions were present in 20 (74%) cases. The respiratory system was the most frequently
documented organ dysfunction in 17 cases (63%), followed by the renal (n = 14, 52%) and
hepatic system (n = 12, 44%).
Substandard care factors which contributed to death were identified in 25 women (93%).
Delay in reaching care occurred in four women (15%), while delay in receiving care in the
hospital occurred in 24 women (89%) (Table 4).
Delay in monitoring & diagnosis. The expert committee identified delay in the diagnosis
of sepsis in 17 women (63%). Inadequate monitoring occurred in 16 women (59%). In Fig 3
the adapted SIRS-criteria that were used and reported by clinicians in the 27 cases are shown.
Respiratory rate was the most poorly reported vital sign, reported in only 13 women (52%).
Temperature was below 36 degrees in five women (18%) and white blood cell count was
normal in seven women (26%). Information on mental state was missing in 19 women (70%).
In-depth analysis of the maternal deaths with sepsis as the underlying cause (n = 17) is
provided in Fig 4 and the supplementary files S1 Table and S1 Fig. Vital signs were taken upon
admission in all cases, though any of the vital signs were rechecked within 24 hours in only
seven septic women. According to documentation temperature, pulse and blood pressure were
rechecked within 24 hours in respectively four (24%), five (30%), and six (35%) women. Organ
dysfunction was already present when initial signs of sepsis were manifest in 15 of the 17
women. In two women no information was available because no laboratory tests were done at
the time sepsis was diagnosed.
Urine cultures positive
n = 3/13 (23%)
Sputum cultures positive
n = 4/6 (66%)
Pseudomonas aeruginosa [n = 2]
Klebsiella pneumoniae [n = 2]
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Fig 2. Number of sepsis-related maternal deaths showing different organ system dysfunctions (n = 27).
Delay in treatment and the golden hour principle. The committee agreed that there was
delay in treatment in 22 women (81%). Intravenous antibiotic treatment was given in 25 of the
27 women (93%). In 12 women (44%) empiric antibiotic treatment appeared to be right
according to the culture sensitivity profiles. In eight women (30%) frequent switch in
antibiotics, with more than three different regimes, was given within three days, without sensitivity
profiles known. In-depth analysis of the maternal deaths with sepsis as the underlying cause
(n = 17) illustrated that 15 women (88%) had already signs of severe sepsis when admitted in
the hospital. In none of those women antibiotics were administered within the first hour of
diagnosis of sepsis (Fig 4). Mean (SD) time between the first sign of sepsis and initiation of
intravenous antibiotic treatment was 12.5 hours (SD 5, range 2±48 hours). In five (29%)
women intravenous antibiotics were administered more than 24 hours after the onset of sepsis.
n = 27 (100%)
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Fig 3. Clinical signs when sepsis was diagnosed in the sepsis-related maternal deaths in Suriname between 2010
and 2014 (n = 27).
No intravenous antibiotics were administered in two women: in one case the woman died
within two hours after the diagnosis and in the other woman antibiotics were given orally.
Other substandard care factors. Delay due to miscommunication between health care
professionals occurred in ten cases (37%) (Table 4). An example where miscommunication
occurred is the case of direct maternal death from sepsis after manual placenta removal: one
gynaecologist prescribed primperan (a gastrointestinal stimulant) for vomiting in this women
with a bumped and shiny belly and another stopped it the next day considering primperan to
be contra-indicated when an intestinal obstruction is suspected. In three cases (11%) an
Intensive Care bed was requested but not available. In one case (4%) blood was not available for
transfusion. The expert committee agreed that substandard care factors definitely or most
probably led to death in 10 of the 27 women (37%).
Fig 4. Overview of the time between admission, first signs of sepsis, first vital signs after admission, the initiation
of antibiotic treatment and death per patient with sepsis as the underlying cause of death (n = 17). Legend: initial
signs of sepsis designated with a gray triangle, use of antibiotics designated with grey rhombus, death designated with a
black cross, vital signs recorded after initial signs of sepsis designated with a grey circle.
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This is the first detailed clinical study of pregnant and postpartum women dying of sepsis in
Suriname. Of all 65 maternal deaths from 2010±2014 in Suriname 29 (45%) were sepsis related
and in 17 of these women (27%) sepsis was the leading underlying cause of death. The
attribution of sepsis to maternal deaths in Suriname was much higher than the 8.3% reported in Latin
America and Caribbean or the 10.7% worldwide [
]. In Brazil, however, infection was
responsible for nearly half (46%) of all facility-based maternal deaths, much higher than previously
]. While various high-income countries performed extensive qualitative studies on
sepsis-related maternal mortality and morbidity, there is scarce data from middle- or
lowincome countries [9,10,19±22].
Three major findings of our study were identified: first, most sepsis-related maternal deaths
occurred in women with low economic status and postpartum, within one week after delivery;
second, the most common identified source of sepsis causing maternal deaths in Suriname
was pneumonia; and finally, there was a major delay in monitoring, diagnosis and prompt
treatment with regards to the golden hour principle.
Classification and causes of sepsis-related maternal deaths
Classifying the cause of maternal death is a complex matter with great classification differences
between countries [
]. WHO guideline for ICD-MM classification states that the underlying
cause of maternal death is where the chain of events leading to death starts. The ICD-MM
classification system, however, impedes for example ªa death with an abortive outcomeº to be
classified as a ªpregnancy-related infectionº. Also, a woman can only have one underlying cause of
death for classification purposes. One of the cases in our study, a woman who died due to
complications (sepsis) of a mechanically-induced abortion, was classified as ªa death with an
abortive outcomeº, would not be included in this study if only underlying causes were studied.
Similarly, another case of a woman with cerebral bleeding due to hypertensive disorder who
died due to a sepsis caused by the craniotomy wound, would not have been included (sepsis as
mode of death).
While malaria in pregnancy caused maternal mortality in the nineties in Suriname (4,7%,
n = 3/64), no maternal deaths due to malaria have been diagnosed between 2010 and 2014.
] This is in line with the numbers in the general population: deaths from malaria have
declined with 92% since 1990 .
Pneumonia was the most common source of sepsis in Suriname. Accordingly, as in the UK,
not only genital tract sepsis but more importantly non-obstetric causes as especially
pneumonia, but also urosepsis were reasons for maternal mortality [
]. The attribution of indirect
causes has been increasing globally [
]. An improved enquiry and registration of deceased
women on non-obstetric wards, as done in this study, can also be the result of the relative
increase of indirect maternal deaths in middle-income countries. Because a RAMoS was done
nationwide, also indirect deaths at other wards than the maternity ward were included, leading
to more non-obstetric cases as pneumonia [
Delays in reaching health care facilities were not a major problem (n = 4/27, 15%). Each year
only 5% (n = 500/10.000) of deliveries take place in the rural interior and these are mainly low
risk pregnancies. However, delays in receiving quality care in health facilities occurred more
frequently (n = 24/27, 89%): there was delay in monitoring, diagnosis and treatment of
sepsisrelated deaths [
]. Suriname, with a MMR of 130, could be classified as stage III in the WHO
model of ªobstetric transitionº, which describes the shift of countries from high MMR to low
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]. In this stage of transition indirect causes such as non-obstetric sepsis, are becoming
important contributors to maternal deaths, whereas direct maternal deaths still remain
significant. In this model essential recommendations to reduce maternal mortality for stage III
include improvement of quality of intra-hospital care (third delay), with skilled birth
attendance and appropriate management of complications [
]. Therefore, we focus on these
delays in health facilities in greater detail.
Monitoring. Adequate monitoring of pregnant women for clinical signs of infection in
early stages is crucial [
]. To identify critically ill pregnant women a modified early
obstetric warning score (MEOWS) could be used . To perform MEOWS systolic blood pressure,
diastolic blood pressure, respiration rate, heart rate, oxygen saturation, temperature and
conscience level should be assessed repeatedly. Recognition of predetermined abnormal values of
these vital signs should lead to an adequate medical response [
]. In this study substandard
care by poor monitoring occurred in 16 of 27 women (59%) and there had been inadequate
recognition of early warning signs. No structural scoring of vital parameters as the MEOWS
was used. In all sepsis-related cases initially there was a tachypnea of more than 20 respirations
per minute (documented in 48% of the records) and / or a tachycardia of more than 100 per
minute indicating first signs of severe sepsis [
]. However, these early signs of sepsis were not
recognized in nine women (32%) as they died on the ward without receiving adequate
monitoring and treatment.
Clinical characterization of sepsis may be achieved by performing a SOFA (sepsis-related or
sequential organ failure assessment) score, which determines the extent of organ dysfunction
]. Though SOFA is not validated in pregnant women, a simplified form of SOFA, the
quick SOFA or qSOFA (respiration rate 22 / minute, altered mentation and systolic blood
pressure < 90 mm/Hg) can be used as a simple bedside test to identify women with suspected
infection associated with poor outcome. Respiratory rate also seems to correlate with severity
of sepsis . In this study we did not use qSOFA as diagnostic or prognostic criterium as it is
not validated in pregnant women. More importantly information on respiration rate (n = 13,
(48%)) and mentation (n = 19, 70%) were often missing in our population and it was therefore
not possible to assess qSOFA scores.
Diagnosis and treatment. This study illustrated that delay in monitoring led to delay in
diagnosis and treatment of sepsis. Even when sepsis was recognized, in none of the cases
antibiotic treatment was started within one hour. According to the Surviving Sepsis Campaign
guidelines any sign of infection should promptly be recognized and treated [
fluid resuscitation and early and appropriate antibiotic treatment is the best way to manage
]. Antibiotic treatment should be started within one hour (golden hour principle)
Recommendations to prevent maternal deaths from sepsis in Suriname
From this maternal death from sepsis analysis we could distillate three major
recommendations for maternal care in Suriname: 1) improve postpartum care, 2) introduce a maternal
sepsis bundle for diagnosis and 3) early treatment of pregnant and postpartum women in close
collaboration with other medical disciplines.
Since most deaths occurred after delivery, it is vital to provide women with sufficient
information of danger signs when discharged after delivery. Furthermore, the initiation of a
structured postpartum care system in Suriname is crucial.
The introduction of a structured recording of vital signs (as MEOWS) is strongly
recommended in order to identify critically ill septic patients[
]. Sepsis performance improvement
programs which includes guidelines on monitoring, prevention and early treatment of sepsis
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are necessary [
]. Introduction, implementation and adherence to Surviving Sepsis Campaign
(SSC) bundles (a set of recommendations for sepsis screening and treatment) could enhance
the care for septic pregnant and postpartum women in hospitals. Selection of an optimal
intravenous empiric antimicrobial regimen is the cornerstone of the treatment of sepsis [
nationwide guideline should be developed and implemented in Suriname.
As non-obstetric causes of sepsis are becoming more important, a multidisciplinary
approach in treatment of sepsis is essential [
]. Collaboration of obstetricians with other
physicians as internal medicine specialists, microbiologists, nurses, and pharmacists is
Strengths and limitations
Regarding the difficulties collecting clinical data from medical records in a middle-income
country, this extensive dataset is unique and valuable. There are, however, some limitations.
Cases were analysed and classified by the expert committee based on information of medical
records, in which documentation was not always sufficient and sometimes information was
missing. However, the local team was accustomed to these records and scrutinized all medical
information for signs of recognized medical comorbidities predisposing pregnant and
postpartum women to infection including obesity, diabetes mellitus, HIV / AIDS, hepatitis, sickle cell
disease, malaria, malnutrition, multiple gestations and severe anemia [
in this study information on weight and nutrition of the women was not available. At the
moment we are prospectively collecting morbidity data for all pregnant women in Suriname.
Finally, while WHO launched the new definition of maternal sepsis, it remains difficult to
compare data between countries because various criteria and definitions are used [
WHO GLOSS, the Global Maternal Sepsis Study, in more than 500 healthcare facilities in 53
countries will address these issues [
Sepsis was the leading cause of maternal death in Suriname, with most deaths occurring after
delivery. Non-obstetric causes (as pneumonia) were the most important primary contributors
to sepsis. Monitoring of critically ill septic patients was inadequate and antibiotics were not
started within the ªgolden hourº. A uniform international definition of sepsis in pregnancy /
postpartum with clear criteria is mandatory for early recognition of sepsis. Close monitoring
and prompt treatment of patients with sepsis is essential. Introduction of early sepsis warning
signs, guidelines on postpartum care and introduction and implementation of SSC bundles for
pregnant and postpartum women could prevent maternal deaths from sepsis.
S1 Table. Vital parameters in the 17 cases with sepsis as underlying cause.
S1 Fig. Figures of the vital parameters in the 17 cases with sepsis as underlying cause.
The authors wish to thank the Ministry of Health of Suriname, the Bureau of Public Health
and the Central Bureau of Civil Registration for their support, as well as the hospital boards of
all hospitals in Suriname, Regional Health Services and Medical Mission for making this study
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possible. We are also thankful to the members of the expert committee who carefully analysed
Conceptualization: Lachmi R. Kodan.
Data curation: Lachmi R. Kodan, Kim J. C. Verschueren.
Methodology: Lachmi R. Kodan, Kim J. C. Verschueren, Marcus J. Rijken.
Supervision: Humphrey H. H. Kanhai, Jos J. M. van Roosmalen, Kitty W. M. Bloemenkamp,
Marcus J. Rijken.
Validation: Marcus J. Rijken.
Writing ± original draft: Lachmi R. Kodan.
Writing ± review & editing: Kim J. C. Verschueren, Humphrey H. H. Kanhai, Jos J. M. van
Roosmalen, Kitty W. M. Bloemenkamp, Marcus J. Rijken.
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