Maternal and neonatal sepsis is a generalized inflammatory response with systemic manifestations caused by one or more infectious agents (1), which occurs during pregnancy, childbirth, after abortion, or during the postpartum period (42 days) in women or in the first 28 days of life in newborns (2–4). Sepsis is a major cause of maternal and neonatal morbidity and mortality (2, 3, 5–9). It is the third leading cause of death in women and accounts for a quarter of neonatal deaths (1, 10–14). It is an obstacle to achieving the third Sustainable Development Goal (SDG), which aims to reduce maternal and neonatal mortality and morbidity (15). Low- and middle-income countries (LICs) are particularly affected by maternal and neonatal sepsis (11, 16, 17). In sub-Saharan Africa (SSA), it is estimated to be responsible for 130,000 maternal deaths and 300,000 neonatal deaths per year, although this may be an underestimation (2, 18). These deaths reflect a number of challenges, including policy, poverty, health inequalities, and the health system (19). However, few data are available on the prevalence and factors associated with sepsis across the continuum from pregnancy to postpartum or post-abortion, making it difficult to make a real estimation of maternal and neonatal sepsis in these countries (2, 10, 11). In the literature, the factors associated with maternal and neonatal sepsis are diverse, including prolonged labor, failure to perform antenatal consultation (ANC), prolonged rupture of membranes, history of infection in the mother, repeated vaginal examinations, intrapartum fever, gestational age, parity, type of delivery, prematurity, chorioamnionitis, meconium-stained amniotic fluid, Apgar score < 7, low birth weight < 2.5 kg, resuscitation of the newborn, age of the newborn <7 days, and male sex (5–7, 20–23).

Prevention, early recognition of signs, and rapid and appropriate management of cases are the main factors associated with a reduction in the morbidity and mortality associated with maternal and neonatal sepsis (5, 11, 24–26). A recent meta-analysis carried out in SSA in 2022 identified several risk factors for neonatal sepsis (27) but did not explore the magnitude of neonatal and/or maternal sepsis nor the factors associated with maternal sepsis. Other studies have shown that the prevalence of maternal sepsis was 39% in Ethiopia (28), 12.20% in Keyna (29), and 20% in Tanzania (30); for neonatal sepsis, it was 77.9 in Ethiopia (31), 20.5% in South Africa (32), 49.8 in Tanzania (33), 37.6 in Nigeria (34), and 17.5 in Ghana (35). Although these single studies reported data on the prevalence and factors associated with maternal and neonatal sepsis, there are no regionally representative pooled data on the magnitude and factors associated with maternal and neonatal sepsis in SSA. However, a better understanding of the burden and a synthesis of the evidence on the factors associated with maternal and neonatal sepsis are needed to optimize prevention strategies and management guidelines against this scourge. The aim of this systematic review with meta-analysis was to estimate the prevalence and factors associated with maternal and neonatal sepsis in sub-Saharan Africa. To the best of our knowledge, this is the first systematic review and meta-analysis to examine both the prevalence of and factors associated with maternal and neonatal sepsis in SSA. It aimed to answer the following questions:

This systematic review was reported in accordance with PRISMA (Preferred Reporting Item for Systematic Review and Meta-analysis) guidelines (36). The protocol for this review was developed and registered in the “International prospective register of systematic reviews PROSPERO” (ID: CRD42022382050).

A total of 2,638 titles were screened (2,033 from PubMed, 58 from the African Index of Medicus, 41 from Cochrane, and 506 from Google Scholar). After removing duplicates, 2,145 studies remained. Evaluation of titles and abstracts led to the exclusion of 2,019 studies. Nine studies were excluded because the full text was not available. The full-text review involved 126 studies. The number of articles retained for inclusion was 39. The reasons for the exclusion of 87 studies were the lack of availability of the variable of interest and the difference in the target population (Figure 1).

Knowledge of the burden and risk factors of maternal and neonatal sepsis is crucial for developing preventive measures and reducing maternal and neonatal mortality. This systematic review with meta-analysis filled the gaps in the literature on the prevalence of maternal and neonatal sepsis and associated factors in SSA. Based on 39 studies included in the final analysis, we found a pooled prevalence of 19.21% for maternal sepsis and 36.02% for neonatal sepsis. However, considerable heterogeneity was observed.

Factors such as rural residence, parity, prolonged labor, and multiple vaginal examinations significantly increased the risk of maternal sepsis in our study. The factors associated with neonatal sepsis in this review are classified into maternal and neonatal factors. Maternal factors such as prolonged rupture of membranes > 12 h, intrapartum fever, and history of maternal urinary tract infection and neonatal factors such as Apgar score < 7, presence of meconium in amniotic fluid, and male sex were significantly associated with neonatal sepsis. Our estimate confirms that maternal and neonatal sepsis is a major public health problem in SSA. The pooled prevalence of maternal sepsis in our review is in line with other reviews conducted in 2009 (77) and 2021 (20). This high prevalence can be explained by various factors, such as the coverage of childbirth in health facilities, the asepsis and hygiene of surfaces and materials used, the personal hygiene of pregnant women, and certain harmful practices. Our study is the first to examine both the extent and the factors associated with maternal and neonatal sepsis, which sets it apart from other reviews. It identified other factors, such as rural residence and parity, which were not identified in the 2022 review or the WHO guidelines (78). Our results could serve as a broader database for the development of interventions for the prevention and management of maternal and neonatal sepsis.

All the maternal sepsis studies included were from East Africa. The subgroup analysis of the prevalence of maternal sepsis ranged from 15.43% based on clinical signs and biology to 25.33% based on clinical signs.

The subgroup analysis of the prevalence of neonatal sepsis varied from one subdivision to another. East Africa recorded the highest prevalence, 42.96%, which was higher than the pooled prevalence. This could be explained by the weakness of the health system, the quality of services offered, and socio-cultural factors. The under-analysis of sepsis in other parts of Africa, due to the small number of studies carried out there, masks a probable high prevalence in these countries, as areas of high prevalence in these countries have probably not been covered by the small number of studies published. The prevalence of neonatal sepsis was 44.11% for the diagnostic criterion based on clinical signs and 31.25% for clinical signs and biology. Despite the various subgroup analyses, they did not make it possible to explore the source of the heterogeneity. This could be explained by the heterogeneous definition of sepsis in the different studies. The clinical signs differed from one study to another, as did the laboratory tests, which is why a meta-analysis of the individual data was necessary to identify a single algorithm.

The factors associated with maternal sepsis in our review are partly in accordance with a review of the literature in other systematic reviews in 2009 and 2022 (27, 77), where the risk factors identified were intrapartum maternal fever, multiple vaginal examinations, foul-smelling vaginal discharge, prematurity, prolonged rupture of membranes, prolonged labor, and multiple vaginal touches.

Living in a rural area was significantly associated with maternal sepsis. Women living in rural areas were 2.3 times more likely to develop sepsis than those living in urban areas. The possible explanation could be poor hygiene levels, lack of water sources, poor cord care, overcrowding in homes, and low education level of mothers in rural areas (73, 75, 79). Another possible explanation could be the fact that mothers living in urban areas are close to health facilities and have various means of transport to get to these facilities, and the availability of qualified staff and adequate technical platforms in urban areas. A vaginal examination ≥ 5 times was significantly associated with maternal sepsis. The probability of maternal sepsis was 4.4 times higher in women who had undergone a vaginal examination ≥ 5 times compared with those who had not. During vaginal examinations, there is a high likelihood of microorganisms ascending from the lower to the upper genital tract, which can lead to sepsis. Simple interventions accepted to reduce the incidence of maternal sepsis are using sterile and aseptic technical equipment by providers (hand washing, sterile drapes and instruments, and sterile gloves).

The factors associated with neonatal sepsis in our review are in line with other reviews in Pakistan (78), East Africa (21), SSA (27), and India (80), which reported maternal factors such as intrapartum maternal fever, prolonged rupture of water membranes, gestational age < 37 weeks, prolonged labor, multiple vaginal touches, history of maternal urinary tract infection and low socioeconomic status, neonatal factors such as resuscitation at birth, low birth weight < 2.5 kg, Apgar score < 7, absence of crying immediately after birth, meconium-stained amniotic fluid, and male sex.

Intrapartum fever was significantly associated with maternal sepsis. The probability of maternal sepsis was 2.4 times higher in women with a fever during pregnancy than in those without a fever. Intrapartum fever is suggestive of a maternal infection that is transmitted to the baby in utero or during passage through the genital tract, leading to sepsis.

Membrane rupture > 12 h significantly increased the risk of neonatal sepsis, and a history of urinary tract infection in the mother was significantly associated with neonatal sepsis. The water membrane protects the upper genital tract; when it is ruptured, bacteria can proliferate through the dilated cervix into the upper internal genital tract, causing infection. These pathogens also colonize the birth canal, which could contaminate the newborn during passage through the canal. Intrapartum antibiotic prophylaxis has been recommended as an effective practice for at-risk mothers to reduce sepsis worldwide (81).

Having an Apgar score < 7 significantly increased the risk of neonatal sepsis. As a result, the probability of neonatal sepsis was 2.4 times higher in neonates with an Apgar score < 7 compared with those with an Apgar score > 7. This finding is consistent with studies from Iraq (82) and Indonesia (83). Neonates with low Apgar scores tend to have a poor adaptation to extrauterine life due to the stress experienced during labor and therefore are more prone to infection. In addition, resuscitation procedures following birth asphyxia tend to expose newborns to pathogenic microbes. In our study, however, we did not assess birth asphyxia as a risk factor for neonatal sepsis.

Male sex has been identified as a factor associated with neonatal sepsis, and this finding has been made in the journals in India and SSA. However, we suggest further research into this factor to give a more rational explanation.

Our review used an appropriate search strategy, with the combination of global and regional databases reducing the risk of missing relevant regional studies. Duplicate screening and data extraction, as well as rigorous quality assessment of included data and subgroup analysis, was also performed. The relatively high number of included studies for neonatal sepsis is a strength. The number of articles included was small for maternal sepsis (7), which may limit the generalizability of the results. Most of the studies were cross-sectional, which could be a limitation. The majority of studies included in this systematic review were from East Africa, which may affect the generalizability of our results to sub-Saharan Africa. There were also publication biases between studies and a high degree of heterogeneity. We believe that this is an important subject that has not been sufficiently explored and that a meta-analysis of individual data will be necessary.

In our review, the prevalence of maternal and neonatal sepsis was high. Several factors were significantly associated with this prevalence, which could help prevent maternal and neonatal sepsis by developing appropriate standard infection prevention techniques, reducing certain harmful practices, and reducing susceptibility to infection by improving maternal health through nutritional supplementation and treating infections during pregnancy. However, there is a need for evidence on other important risk factors for maternal and neonatal sepsis, including in the community. Given the high risk of bias and high heterogeneity, further high-quality research is needed in the sub-Saharan African context.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

FT: Conceptualization, Formal analysis, Investigation, Methodology, Software, Supervision, Writing – original draft, Writing – review & editing. CS: Conceptualization, Methodology, Writing – review & editing. ED: Conceptualization, Writing – review & editing, Investigation. BC: Investigation, Methodology, Writing – review & editing. SS: Software, Writing – review & editing, Formal analysis. ADi: Formal analysis, Validation, Writing – review & editing. ND: Conceptualization, Investigation, Writing – review & editing. BL: Methodology, Writing – review & editing. MA: Conceptualization, Writing – review & editing. KK: Formal analysis, Software, Supervision, Writing – review & editing. AT: Supervision, Writing – review & editing. AC: Writing – review & editing. ADe: Supervision, Validation, Writing – review & editing. HS: Supervision, Validation, Writing – review & editing. IT: Formal analysis, Writing – review & editing.