What is the issue?

Infections that occur during childbirth can result in considerable ill health and even death for the mother or her infant. The risk of infection is believed to be higher for births in healthcare facilities in low-resource settings than in well-resourced settings, as a result of poor hygienic conditions, inadequate water and sanitation systems, overcrowding and low health professional-to-patient ratios. The prescription of antibiotics after an uncomplicated vaginal birth has become routine practice to overcome this situation in some low-resource settings.

Why is this important?

Faced with increasing antimicrobial resistance because of misuse and over-prescription of antibiotics, we need evidence about the effect of routine intake of antibiotics for preventing infections after a normal vaginal pregnancy without complications.

What evidence did we find?

The review assessed whether routine antibiotic treatment after uncomplicated vaginal birth, compared with either placebo or no antibiotics, prevents maternal infection. We searched for evidence in August 2017 in three databases. We identified three trials involving 1779 women. The quality of the evidence ranged from low to very low. Different antibiotics were administered in the three trials and for different lengths of time. The trials took place in the 1960s (one trial) and 1990s (two trials), and were carried out in France, the USA and Brazil.

Routine antibiotic administration reduced the number of women with infection of the lining of the uterus (endometritis) (2 trials, 1364 women) by 70%. The use of antibiotics did not reduce the incidence of urinary tract infections (2 trials, 1706 women), wound infections after episiotomy (2 trials, 1364 women) or length of maternal hospital stay (1 trial, 1291 women).

There were no differences between the groups for skin rash due to antibiotics, reported in one woman in each of the two trials (1706 women). The cost of care was higher in the group that did not receive antibiotic prophylaxis. The incidence of severe maternal infections and illness, antimicrobial resistance or women’s satisfaction with care were not addressed.

What does this mean?

The small number of trials limits the interpretation of the evidence for routine use of antibiotics after normal vaginal births. The low incidence of endometritis in the studies suggests that a relatively large number of women may have to be treated to avoid a few case of infection.

There needs to be a balance between women’s needs, childbirth setting and provider experience (for example, with frequent vaginal examinations or interventions) and the public health threat of antibiotics resistance.

Further research from well-designed randomised controlled trials would help to evaluate the added value of routinely giving women antibiotics after normal vaginal birth to prevent maternal infections.