Antimicrobial—or antibiotic—resistance poses an urgent problem for midwives and public health authorities on a global level. Antimicrobial resistance is defined by the National Institute for Health and Care Excellence (NICE) as:
‘The loss of effectiveness of any anti-infective medicine, including antiviral, antifungal, antibacterial and antiparasitic medicines.’
Society now faces the prospect of a future without antibiotics, since it is estimated that 70% of the world's bacteria have developed resistance to antibiotics (Public Health England, 2015). There are various factors that are believed to have caused this situation, which include (Public Health England, 2015):
Before the discovery of penicillin in 1928, an average of 1 in 10 individuals died from meningitis, pneumonia and skin infections, compared with today's rate of 1 in 100 (Ashiru-Oredope, 2015). Similarly, deaths from childbirth-related sepsis were 3 in 100 before antibiotics and are now less than 3 in 100 000 (Ashiru-Oredope, 2015). Indeed, the World Health Organization (WHO) have estimated that antibiotics have extended human lifespan by approximately 20 years (WHO, 2014). Nevertheless, the emergence of multiple resistant organisms, associated with misuse of antibiotics, has contributed to a post-antibiotic era, where the protection that antibiotics have conferred for so many years is no longer reliable (Shute, 2015).
In the absence of effective antimicrobial treatment, treatable illnesses (such as ear, tooth and urine infections) may become life-threatening; a risk that may be compounded by the increased use of caesarean section (Royal College of Obstetricians and Gynaecologists (RCOG), 2016). From a clinical perspective, a world without antibiotics would be comparable to the 1920s, where sepsis from ascending genital tract infection was the most frequent cause of maternal mortality (Chamberlain, 2006). Antimicrobial resistance could therefore be costly, both to health outcomes and to the NHS, which is facing both cuts to services and the challenge of increasingly finite resources.
Factors associated with antimicrobial resistance
Resistance to antimicrobials may be acquired through genetic mutations or through the transfer of resistance genes from other bacteria via small pieces of DNA known as plasmids (Allison, 2011). Bacteria use several mechanisms to render themselves resistant to all antibiotics, or to a discrete class, such as the penicillins. Worryingly, it is reported that if resistance continues, deaths attributed to antimicrobial resistance could reach ten million by 2050 (O'Neil, 2015). Approximately 80% of antibiotics are prescribed in the primary care setting (Standing Medical Advisory Committee Sub-Group 1998; Public Health England, 2015), and for self-limiting viral infections, such as colds and flu, inappropriate prescribing is widespread (Cole, 2014). Shallcross and Davis (2014) reported that contributing factors included:
Antimicrobial resistance therefore requires a multi-faceted approach, and co-ordinated action, if it is to be minimised. In the absence of any new, effective antibiotic, it is essential to eliminate inappropriate antibiotic use, to limit appropriate antibiotic use to instances of real need, and to ensure that patients comply with regimes for taking antibiotics. Health professionals and the general public therefore both have a role in limiting the spread of resistance. By providing appropriate guidance in the form of an information card containing key messages about using antibiotics wisely, something that could be kept in a wallet or purse, for example (Allison et al, 2017) (Box 1), the volume of antibiotics being prescribed and dispensed unnecessarily may be reduced.
A key strategy in helping achieve this is in promoting effective, antibiotic stewardship, which is defined as:
‘An organisational or healthcare system wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness.’
In addition to global and national stewardship initiatives, local interventions in all clinical settings are also required.
The midwifery perspective
Common infections in maternity care
Common infections in pregnancy involve the respiratory and urinary tract, and may result in adverse outcomes (Adams-Waldorf and McAdams, 2013). The maintenance of overall health is therefore vital in reducing infection and antibiotic prescription. For example, optimal nutrition is especially important in reducing anaemia, which reduces immunity to infection (Baingana et al, 2015). Smoking cessation will also minimise maternal respiratory infections in pregnancy (Feldman and Anderson, 2013), as respiratory infections range from colds to influenza and account for one in eleven maternal deaths in the UK (Knight et al, 2014). Midwives should be vaccinated against H1N1 influenza virus (swine flu) and advise that pregnant women also be vaccinated (Ponnampalan et al, 2011). In this way, the use of antibiotics may be reduced by 10 prescriptions per 1000 population (Kwong et al, 2009). Other preventative strategies include:
Less evidence is available regarding the prevention of urinary infections in pregnancy. However, preventative strategies include (Schneeberger et al, 2015; Lamb and Sanders, 2016):
Associated factors for infection in maternity care
Susceptibility to infection and associated antibiotic treatment in pregnancy is an important clinical issue for midwives, as globally, 10.7% of all maternal deaths are sepsis-induced (Say et al, 2014). This is not necessarily confined to low-resource economies: in the UK, sepsis, defined as ‘infection plus systemic manifestations of infection’ (RCOG, 2012: 2) accounted for 11 deaths per 100 000 maternities in 2006–2008 and 2.04 deaths per 100 000 in 2009-2012 (Knight et al, 2014). Despite continued efforts, sepsis still accounts for direct maternal deaths in the UK (Knight et al, 2016); however, recent ‘Think sepsis’ campaigns have helped midwives to remain vigilant (Knight et al, 2014; NHS England, 2015).
Midwives should be aware that altered pregnancy physiology as the main rationale for infection is over-simplistic (Soma-Pillay et al, 2016). Indeed, it seems that a modulated immune response as pregnancy advances impairs the ability to fight a range of organisms (Robinson and Klein, 2012). Specifically, it is this reduced adaptive immunity that renders pregnant women particularly vulnerable to more severe infections (Kourtis et al, 2014). Mortality associated factors may include:
Put simply, a diagnosis of infection increases the risk of antibiotic exposure in pregnancy, meaning that antibiotic stewardship is an important part of the midwife's role.
Midwives' role in antibiotic stewardship
Antibiotic prescription is common in pregnancy (Kuperman and Koren, 2016), with mastitis, endometritis, perineal wounds and neonatal sepsis all common infections requiring treatment (Arulkumaran and Singer, 2013; Tambe et al, 2015). Obesity also predisposes women to surgical wound infections (Nobbs and Crozier, 2011, Tipton et al, 2011). With a pregnant woman recently receiving carbapenem for a coliform-resistant infection (O'Callaghan, 2017), the potential for antibiotic resistance cannot be overstated. Midwives can promote antibiotic stewardship by minimising the risk of infection, and promoting compliance with antibiotic treatment.
Minimising the risk of infection
Antibiotic stewardship and minimising infection are essential components of safe and competent practice as defined by the Nursing and Midwifery Council (NMC) Code (NMC, 2015). However, Ackerley (2009) reported that basic hand washing was not necessarily embedded in clinical practice. This is crucial, since there were two UK deaths due to Streptococcus A sepsis, suggested to be caused by transmission of infection from a sore throat, to hands, and then onto the perineum (Buddeberg and Aveling, 2015). Midwives should therefore advise women on (Starlander et al, 2010; Arulkumaran and Singer, 2013):
Feeding and minimising infection
Ideally, babies should be exclusively breastfed for at least 6 months (WHO, 2017), as breastfed infants are less likely to succumb to gastrointestinal infections, meaning that they avoid antibiotic exposure. Midwives may also minimise infection (and thereby avoid the use of antibiotics) by advising on correct expression and storage of breast milk.
Correct expression of breast milk is important, since antibiotics are commonly prescribed for mastitis (Arulkumaran and Singer, 2013). Mastitis can, however, be minimised by facilitating skin-to-skin contact simmediately after birth, promoting an effective latch to the breast and managing sore breasts/nipples (Buck et al, 2014). Emptying of the breast and the management of engorgement postpartum are crucial (Pustotina, 2016). Safe storage of breast milk will minimise contamination (The Breastfeeding Network, 2014), and scrupulous sterilising procedures for safe preparation and storage of formula feeds and breast pumping equipment are also important (NHS et al, 2015).
Infection control
Midwives therefore have a key role in helping to reduce maternal and neonatal infection with respect to feeding; however, they also have a wider remit in infection control. The vast majority of midwives practise in hospital, and should prioritise infection control in order to reduce nosocomial contamination. National guidelines (Altimier, 2010; RCN, 2012; Arulkumaran and Singer, 2013; Loveday et al, 2014; Zalewska, 2016) state that infection control includes:
Antibiotic compliance in minimising antimicrobial resistance
Infection control measures are important in minimising infection; however, prevention of infection is not always feasible. Thus, where antibiotics are prescribed, it is important to promote effective compliance, as failure to do so will increase antimicrobial resistance (Uchil et al, 2014). Appropriate antibiotic therapy is an important treatment against some infections; indeed, more prompt antibiotic treatment could have reduced the number of maternal deaths due to sepsis (Mohamed-Ahmed et al, 2015). Antimicrobial resistance can also be minimised through the correct prescription of antibiotics and compliance with prescribed courses of treatment (Cordioli et al, 2013; Yealy et al, 2015).
Midwives should support compliance with drug regimens and advise women on the duration of treatment and any possible interactions (NICE, 2015). Midwives must also be aware that longer courses of antibiotics are associated with failure to complete the treatment, as improvements in health are often noted before completion, meaning that any remaining bacteria are exposed to a diminished dose, survive and multiply in resistant forms (McNulty et al, 2013). Research has shown that ‘once daily’ dosing regimens are useful in promoting antibiotic stewardship (Falagas et al, 2015). Midwives may find the FRAIS mnemonic helpful (Fleming, 2016) in promoting compliance, which stands for:
Midwives play an important role in providing accurate information to pregnant women, especially if women have concerns regarding medication and its effect on the fetus; a factor that Nordeng et al (2010) reported was a barrier to that pregnant women taking prescribed medication. In addition, midwives also need to be aware of postpartum adjustment; whereby fatigue and lack of routine may affect antibiotic compliance (Wiegers, 2006).
Hämeen-Anttila et al (2014) also reported that the range of information at pregnant women's disposal contributed to conflicting advice, anxiety, and non-compliance with medication. Specifically, women with reduced health literacy required tailored and detailed advice in clear and easily accessible verbal or written formats (Hämeen-Anttila et al, 2014). Others have argued that, in an increasingly busy NHS, it is important to allow opportunities for discussion of concerns if treatment compliance is to be successful (Twigg et al, 2016).
Conclusion
Antimicrobial resistance is a concern, with serious consequences for treating even minor infections in a post-antibiotic era. Advancing pregnancy and altered immunity may increase vulnerability to infections, most notably those that are respiratory or genito-urinary. Associated factors for developing infection during the childbearing continuum are complex and require a multi-faceted approach, and sepsis remains an important cause of direct death in the UK, where more prompt treatment with appropriate antibiotics could have reduced deaths. There is therefore a need to reduce infection and unnecessary exposure to antibiotics in order to reduce antimicrobial resistance.
Maternity care for labour and birth is predominantly hospital-based, where interventions and mode of birth may increase nosocomial infection. Midwives consequently have a significant role to play in antibiotic stewardship by promoting public health advice on healthy lifestyles, use of appropriate interventions, and strict adherence to infection control protocols. Midwives should advise women on how to minimise infection risk, particularly in respect of basic hygiene practices where signs of infection are evident, and in feeding and caring for their babies. Finally, midwives can help to reduce antimicrobial resistance by promoting and facilitating compliance with prescribed antibiotic regimens and providing guidance on basic hand-hygiene measures.
Multidisciplinary working and learning are the hallmarks of a service that seeks to deliver safe, effective care to women and their babies; hence, shared expertise between midwives and pharmacists will posit antibiotic stewardship at the top of the NHS agenda. Ultimately, clinical practice does not occur in a vacuum: curriculum development teams working cohesively in higher education serve to facilitate a culture of both supportive teaching and learning, whereby the health professionals of the future will help to forge better outcomes for women and babies.