The effect of surveillance and appreciative inquiry on puerperal infections: a longitudinal cohort study in India

Julia Hussein, KV Ramani, Lovney Kanguru, Kalpesh Patel, Jacqueline Sarah Bell, Purvi Patel, Leighton Walker, Rajesh Mehta, Dileep Mavalankar

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To evaluate the effects of an intervention comprising surveillance and an organisational change called Appreciative Inquiry on puerperal infections in hospitals in Gujarat state, India.


This longitudinal cohort study with a control group was conducted over 16 months between 2010 and 2012. Women who delivered in six hospitals were followed-up. After a five month pre-intervention period, the intervention was introduced in three hospitals. Monthly incidence of puerperal infection was recorded throughout the study in all six hospitals. A chi-square test and logistic regression were used to examine for associations, trends and interactions between the intervention and control groups.


Of the 8,124 women followed up, puerperal infections were reported in 319 women (3.9%) over the course of the study. Puerperal sepsis/genital tract infections and urinary tract infections were the two most common puerperal infections. At the end of the study, infection incidence in the control group halved from 7.4% to 3.5%. Levels in the intervention group reduced proportionately even more, from 4.3% to 1.7%. A chi-square test for trend confirmed the reduction of infection in the intervention and control groups (p<0.0001) but the trends were not statistically different from one another. There was an overall reduction of infection by month (OR = 0.94 95% CI 0.91–0.97). Risk factors like delivery type, complications or delivery attendant showed no association with infection.


Interruption of resource flows in the health system occurred during the intervention phase, which may have affected the findings. The incidence of infection fell in both control and intervention groups during the course of the study. It is not clear if appreciative inquiry contributed to the reductions observed. A number of practical and methodological limitations were faced.
Original languageEnglish
Article numbere87378
Number of pages10
JournalPloS ONE
Issue number1
Publication statusPublished - 30 Jan 2014


  • maternal health
  • puerperal infections
  • appreciative inquiry
  • india

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