Factors influencing health promotion behavior on puerperal sepsis among postpartum mothers

Abstract

Puerperal sepsis is accountable for maternal death worldwide. The health promotion behaviour of postpartum mothers may contribute to preventing puerperal sepsis, which would promote maternal health. The study aims to identify the factors influencing health promotion behaviour on puerperal sepsis among postnatal mothers. A descriptive correlational study design was conducted among 112 postpartum women conveniently selected from Dhaka Medical College Hospital. The measures were personal characteristics questionnaire, perceived benefits questionnaire, perceived barrier, postpartum social support and puerperal sepsis preventive behaviour questionnaire. Data were collected and analyzed by the researcher using descriptive and inferential statistics. Descriptive statistics describe descriptive variables, such as mean, SD, frequency, and percentage. The inferential statistics Pearson’s correlation, t-test, and ANOVA were used to describe the relationship among study variables. The mean age of participants was 25.4(SD = 5.14) years old. The socio-demographic characteristics of income (r = 0.24, p = 0.01)., residence (t= -2.12, p = 0.001) and ANC (t= -3.28; p = 0.001) visits were associated with puerperal sepsis preventive behaviour. In addition, the perceived benefit was positively associated (r = 0.62; p = 0.001) with puerperal sepsis preventive behaviour and the perceived barrier was found to be negatively correlated (r=-0.55, p = 0.001). The study findings help increase postpartum mothers’ awareness about the benefits of puerperal sepsis preventive behaviour. Findings may be recommended for further experimental study to develop and assess the effect of health promotion guidelines on puerperal sepsis.

Introduction

Puerperal sepsis is one of the leading causes of maternal death and is accountable for 11% of maternal deaths globally [1]. Puerperal sepsis is an infection of the genital tract occurring at any time between the rupture of the membrane during labour and 42 days of the postpartum period, presented by pelvic pain, fever, abnormal vaginal discharge, abnormal or foul odour discharge, and delayed involution [2]. The mode of delivery and chronic maternal disease are potential risk factors for developing puerperal sepsis [3]. Anemia, prolonged labour, frequent vaginal examinations in labour under unsterilized circumstances, and premature rupture of membranes for prolonged periods are common predisposing factors of puerperal sepsis [4]. According to Priyanka et al. [5], puerperal sepsis is the 2nd leading cause of maternal mortality, as 19.2% of maternal deaths are due to puerperal sepsis. Worldwide, the puerperal sepsis rate is 15%, and in India, it is 11%0.4, which is significantly associated with the knowledge of health personnel regarding aseptic techniques during delivery and years of working experience in the labour room [6]. Regarding the practices of postnatal women, the forestallment of puerperal sepsis revealed that giving birth at a public institution, consuming a balanced diet and plenty of fluids during postpartum, abstinent from sexual exertion, visiting health institution after notice of leakage of liquor instantly, maintaining perineal hygiene during the puerperium, using soft and aseptic pads, monitoring the colour and odour of lochia, seeking medical care for any complain or crack during puerperium, taking prescribed antibiotics and plenty of rest are significant [7]. Globally, 75,000 maternal deaths occur yearly as a result of puerperal sepsis reported in Asia 11.6%, Africa 9.7%, South America 7.7%, and the Caribbean 7.7% countries [8]. The rate of puerperal sepsis for vaginal delivery is 5.5%, and in cesarean delivery is 7.4% in the USA, and the death rate due to puerperal sepsis is 3 per 100,00 deliveries [9]. In Bangladesh, puerperal sepsis incidence rate is 4.5 per 100 live births [10]. In developed countries, puerperal sepsis contributes only 2.2% of maternal mortality [11]. Compared to the past decades, Bangladesh, as a developing country, is now a more desirable health condition [12].

The most effective and least expensive treatment of postpartum infection is practising preventive behaviours, including maintaining perineal hygiene and taking good prenatal nutrition to control anaemia and intrapartum haemorrhage [13]. However, increasing incidences of maternal mortality are due to a scarcity of information regarding puerperal sepsis and due to negligence of puerperal sepsis [14]. Traditional beliefs and practices are the major obstacle to improving postnatal care for women in Bangladesh [15].

Health promotion behaviours comprise increasing healthy behaviours and replacing unhealthy behaviours to improve functional ability and quality of life [16, 17]. The theory of health promotion model guides health-promoting behaviour that may encourage healthcare providers to stimulate individuals to practice healthy practices [16]. Puerperal sepsis education and knowledge level play a vital role in preventing puerperal sepsis in women of childbearing age, as it is due to lack of knowledge, ignorance, customs, and social practices [7]. In this regard, maternal perceived barriers are to be removed through social support to promote maternal perceived benefits for puerperal sepsis preventive activities, which will contribute to achieving the sustainable developmental goals (SDGs) in Bangladesh as promote maternal health [8].

This study was conceptualised based on Pender’s Health Promotion Model [16] (Fig. 1). This model is a popular health promotion theory used in health science by various researchers to measure health-promoting lifestyles [18, 19], particular health-promoting behaviours/exercise [20–22], health-promoting behavioural outcomes [23], adequacy of prenatal care among pregnant mothers [18] and utilisation of postpartum care [24].

Fig. 1.

Modified puerperal sepsis preventive behaviour model in this study Adapted from “Health Promotion Model (revised),“ [16]

The purpose of this study is to identify the factors influencing health promotion behaviour on puerperal sepsis among postnatal mothers. Some research has been conducted in Bangladesh to determine the level of knowledge and practice regarding puerperal sepsis among postpartum women in private hospitals and postnatal care practice in Indigenous women. However, there is no data found revealing other factors which influence postpartum mothers to adopt health-promoting behaviour during puerperium.

Literature survey

The study aimed to explore the factors influencing health promotion behaviour on puerperal sepsis among postpartum mothers. Thus, literature was reviewed to identify and search for information for better understanding and knowledge about puerperal sepsis. To achieve the desired result, the literature review is organized into the following sections.

Concepts of puerperal sepsis

A substantial contributing cause of maternal fatalities is puerperal sepsis [1]. WHO in 2014 stated that the mother and newborn are most at risk during the postpartum period. In some situations, puerperal sepsis, a frequent pregnancy complication, can cause obstetric shock or even death [25]. Potential risk factors for maternal sepsis include the mother’s chronic illnesses, the pregnancy’s features, and the method of delivery; Chorioamnionitis, endometritis, and pneumonia are the leading causes of sepsis, and 59% of cases involve pregnant and postpartum women who are hospitalised [3]. Contrast agents used for radio diagnostic evaluation during pregnancy may cause anaphylaxis, which is represented by early symptoms like vulvar and vaginal itching, low back pain, uterine cramps, fetal distress, and early labour [26]. Pathogens that infect the vaginal tract are the primary cause of puerperal sepsis in most cases. It generally happens after discharge during the first 24 h of parturition. Among diseases that colonize the cervix and vagina, acquire access to amniotic fluid, and penetrate the devitalized uterine tissues, it is classified as the sixth most common disease burden for women between the ages of 15 and 44, behind depression, HIV/AIDS, TB, abortion, and schizophrenia. Anemia, protracted labour, routine vaginal exams during labour while unsterile, and preterm membrane rupture for an extended length of time are all common risk factors for puerperal sepsis [4]. Premature rupture of membranes leads to preterm delivery, which may be triggered by acute maternal gingivitis or periodontitis [27]. According to a study conducted at the Ife State Hospital in Nigeria, sepsis was predisposed by anemia in 69.2% of cases, prolonged labour (labour lasting more than 12 h) in 65.7% of cases, many vaginal inspections in labour (more than five), and early rupture of membranes (31.5%) [28]. The invasive treatment of PPH, like introducing tamponade and hysterectomy, has a high risk for puerperal sepsis development. Lack of serum potassium and sodium levels during pregnancy leads to PPH during delivery, which needs to be monitored and orally supplemented for the prevention of PPH [29, 30]. It particularly takes place after discharge within side the 1st 24 h of parturition & it is ranked as the 6th main motive of disease burden for girls aged 15–44 years, subsequent to depression, HIV/AIDs, tuberculosis, abortion and schizophrenia [31]. Puerperal sepsis is observed to be substantially correlated with the delivery method. The study found that compared to women who gave birth naturally vaginally, those who delivered via cesarean section had a 2 times lower risk of developing puerperal sepsis [32]. Water immersion during labour can improve maternal outcomes, including pain relief, minimal episiotomy and induction rates, and avoid maternal infection without affecting newborn outcomes [33]. Puerperal sepsis has several morbidities, including endotoxic shock, pelvic abscess, septicemia, vaginal discharge, fever over 38.0 °C (100.4 °F), chills, vaginal discharge, septicemia, peritonitis or abscess formation leading to surgery, and finally mortality [11]. Preeclampsia can potentially lead to puerperal sepsis, which can be detected early through the use of biomarkers like soluble endoglin [34, 35]. Infertility due to tubal blockage is the most serious long-term consequence of puerperal sepsis, affecting 450,000 females per year [36]. The predominant results of puerperal infections are persistent or acute pelvic inflammatory disease, bilateral tubal occlusion and infertility (WHO, 2013). Puerperal sepsis even causes numerous maternal complications (viz., septicemia, endotoxic shock, and peritonitis or abscess) that result in surgical intervention and compromise the opportunity for fertility in future [37].

Prevalence of puerperal sepsis

Globally, 75,000 maternal deaths arise yearly because of puerperal sepsis: amongst this, in Asia, 11.6%, Africa, 9.7%, South America, 7.7%, and Caribbean countries, 7.7% [8]. According to the World Health Organization, around 800 women worldwide pass away each day as a result of complications associated with pregnancy or childbirth, and puerperal sepsis accounts for 15% of these deaths. Ninety-nine per cent of maternal deaths occur in developing nations, and the majority of these deaths can be avoided [4]. According to WHO estimates, there are more than 5 million instances of maternal sepsis annually, or 4% of live births worldwide. There are significant regional differences, with low- and middle-income nations having a more substantial incidence (up to 7%) than high-income ones (1–2%) [4]. In 2017, 808 girls died every day due to being pregnant and transport complications. Almost all these types of deaths came about in growing countries. About 540 of the 808 maternal deaths came about in sub-Saharan Africa and 225 in Asia, in comparison with only four in high-income countries ( [7]. In 2013, over 30.000 maternal deaths (11.0%) were stated postpartum sepsis and is thought to be the third most common reason of about 290.000 maternal deaths worldwide [38]. In Nigeria, puerperal sepsis accounted for 12% of maternal deaths. In Ethiopia, puerperal sepsis accounted for approximately 13% of all maternal deaths and has become one of the pinnacle four reasons for mortality [13]. In Tanzania, the maternal mortality rate remains excessive at an envisioned 556 deaths in step with 100,000 live births and maternal sepsis debts for 16.7% of all deaths [1]. The common countrywide puerperal sepsis occurrence in Tanzania is 29%, which is two times more because the global puerperal sepsis occurrence is anticipated to be 11.23% [14]. Puerperal sepsis (30.9%) turned into the leading cause, accompanied by post-partum haemorrhage (21.6%) in Uganda [20]. In Kenya, puerperal sepsis debts for about 15% of maternal deaths [36]. Studies validated that the superiority of puerperal sepsis had been 16.6% in Pakistan, 68.65% in India and 72.9% in Sudan. The occurrence of puerperal sepsis varies in different hospitals of Ethiopia that’s 5.68% in Dessie referral hospital, 8.4% in Addis Abeba black lion specialised Hospital, 12.9% in Dil-Chora Hospital, 17.2% in the University of Gondar referral hospital, and 33.7% in Felege hiowt referral hospital [8]. Another study showed that the prevalence of puerperal sepsis in Pakistan Gadchiroli district (12.2%), Karachi (11.2%), Sindh (3.89%); Nigeria (1.7%), in Liaquat University Hospital, Hyderabad, Sindh (6.28%), Gujarat state, India (3.9%), in BeniSuef Governorate Egypt (1.5%), Lusaka Zambia (34.8%) Haryana (20.85%,) and in Bangladesh (34.25%) [32]. Above 70% of maternal deaths within side the developing international are due to sepsis & and records suggest that the prevalence of puerperal sepsis in Bangladesh is 4.5 in keeping with 100 live births [10]. Two hospital-based research conducted at Mymensingh Medical College Hospital and Dhaka Medical Collage Hospital in Bangladesh found that maternal mortality from puerperal sepsis in these authorities’ health centres turned 17 and 20.3, consistent with a hundred live births, respectively [10]. On the opposite hand, puerperal sepsis contributes the most effective 2.2% of maternal mortality in advanced countries [11].

Factors associated with puerperal sepsis

To perceive the common socio-economic and demographic elements associated with puerperal sepsis offered at tertiary stage hospitals in Bangladesh, a case-control study was executed in 2016, which exhibits Puerperal sepsis is substantially related to age and literacy level, and the findings reveal that low parity (primiparous and multipara) become drastically related to puerperal sepsis [11]. Mothers having much less than five kids are much more likely to expand puerperal sepsis as compared to the ones having more than five kids. It is, in general, primiparous moms who take a long path of labour and trials in numerous fingers earlier than attaining a health facility [32].

Knowledge regarding puerperal sepsis

Knowledge among postnatal women on the prevention of puerperal sepsis has been proven to be a key component of self-care suggested practice in the prevention of puerperal sepsis [1]. The study concerning knowledge, attitude, and practice (KAP) related to maternal sepsis in Bangladesh and India was taken into consideration as poor [3]. A study in Bangladesh suggested that only 39.3% of observed individuals have a good enough understanding of the preventive practice of puerperal sepsis [7]. A study performed in Tanzania discovered that more than half (n = 213, 62.1%) of the postpartum women had a good enough understanding of preventing puerperal sepsis. Only 39 (11.4%) of the women mentioned good enough self-care practices in the direction of prevention of puerperal sepsis & 52% of the moms in Kuantan had a suitable understanding of maternal sepsis in comparison to the population studied in India in which 36.33% had an excellent degree of information on maternal sepsis [1]. Another study in Bangladesh confirmed a low understanding of maternal sepsis, as 38.7% of participants responded to the questionnaire correctly [3]. A study performed in Egypt confirmed that less than two-thirds of the studied moms had unsatisfactory information concerning puerperal sepsis, and more than 1/2 of them had unsatisfactory practice concerning puerperal sepsis prevention [4]. A study carried out in Egypt confirmed that the terrific majority of the studied women had a bad rating of understanding associated with the definition, causes, symptom, preventive measures and excessive chance group in the pretest (96.0%) respectively [39] mothers exposed to the risk of infection, and eventually endanger their lives due to the lack of knowledge related to puerperal sepsis [4].

Inadequacy of health facilities

About 1 to 8% of vaginal deliveries result in postpartum infection, and it is five to 10 times more common after a caesarean section [10]. Puerperal infections following CS occurred at a rate of 7.4% in the USA, compared to 5.5% in women who gave birth vaginally, according to comprehensive post-discharge surveillance methods used to identify all cases of puerperal infections that occurred in women who gave birth at Brigham and Women’s Hospital, Boston, from January 2011 to June 2015 [28]. During labour and delivery, women may not have access to professional medical care, and any care given in a home or hospital environment by a caregiver who falls short of quality standards might raise the risk of infection [39]. Poor hygienic conditions from the community level to the hospital care level from Cesarean section procedures have been seen to contribute to puerperal sepsis in Uganda, all of which are avoidable risks [28]. Only 5% of facilities in India have a written standard infection control procedure, 70% of facilities don’t use alcohol rubs to clean their hands and reuse surgical gloves for vaginal examinations in the labour room, 33% of facilities don’t have wash basins with “hands-free” taps, and 15% of facilities wipe the surfaces in labour rooms right away after each delivery [40]. Pakistan’s prevalence is reported to be 10–15 per cent, and 90.2% of this is due to poor hygiene practices, particularly inadequate hand washing [28]. In women who developed puerperal sepsis during pregnancy, more vaginal examinations were performed. Over 26.9% of mothers who had sepsis underwent more than six vaginal examinations [28]. In Senegal, women who delivered unassisted by vaginal delivery developed sepsis more often, with an incidence of 8.7% for home deliveries as opposed to 1.9% for deliveries in health facilities [28]. The morbidity of puerperal sepsis is 2.5 times higher among mothers referred from other institutions, and a possible unclean vaginal examination on the way to the hospital is likely to contribute to its development [31]. Access to healthcare facilities, location, and transportation are key to utilising them [12].

Healthcare provider’s role in the prevention of puerperal sepsis

Despite healthcare facilities’ factors, healthcare providers also have an essential role in preventing puerperal sepsis. Puerperal infection is wound infection due to the introduction of pathogenic microorganisms by the hands or instruments of the doctor or nurse [25]. According to the Occupational Health and Safety Act in Ontario, Canada, healthcare providers have the responsibility to comply with infection prevention and control practices according to the act & it is essential to review and follow your healthcare setting infection prevention and control policies. Healthcare providers are uniquely positioned to educate and empower the public with evidence-based knowledge about health promotion and preventive measures related to infection prevention and control. After discharge, follow-up phone calls, hotlines, support groups, lactation consultants, home visits by nurses, and educational materials (videos, documents) are all steps that can be taken to prevent or better detect postpartum infections [13]. However, nurses play an essential role in broadening multidisciplinary methods and intervention plans to cover postpartum women and qualify the care given to contribute decisively to saving and decreasing the rates of puerperal infection [39]. A high proportion of the health facilities reported that staff routinely wash their hands before and after sterile procedures, but only half of the facilities were observed to have 24 h of running water, and only two-thirds had soap and antiseptic solutions in delivery and operating theatre areas [41].

Based on the above, it concluded that puerperal sepsis is the major contributing factor to maternal mortality worldwide, causing compromise of self-esteem of postnatal mothers and also the health of newborns. Being underestimated the consequence of puerperal sepsis, numerous postnatal mothers lose their lives from septic shock and sometimes get admitted to intensive care units. Not only is the negligence of postnatal mothers about their health, but also some economic, cultural, and social barriers are responsible for this public health issue. To mitigate this, the predisposing factors need to be evaluated, and improved practice of self-care during postpartum among women through disseminating health-related knowledge is required. In this regard, a nurse as a health care provider can play a vital role in raising awareness about self-care among postnatal women during discharge from the hospital. Safe childbirth practice using WHO guidelines may be initiated at every healthcare facility, and strict implementation of infection control guidelines is also required.

Health promotion model and puerperal sepsis preventive behavior

The Pander Health Promotion model denotes that six components influence the lifestyle of postnatal mothers [16]. Among the six components in this study, five concepts were utilised to identify the factors influencing puerperal sepsis preventive behaviour among postnatal mothers; these are perceived benefits of action, perceived barriers of action, interpersonal influences, health-promoting behaviours and some personal factors that influence puerperal sepsis preventive behaviour.

Perceived benefits of puerperal sepsis preventive behaviour

According to Pander, perceived benefits of action are the perception of positive reinforcement or consequences of undertaking healthy behaviour [16]. There is limited literature on the perceived benefits of puerperal sepsis preventive behaviour. The research found that perceived health benefits are more significant than health-promoting behaviours. Pregnant women are more likely to want to adopt health-promoting activities because they are more aware of the benefits of doing so [19]. According to studies, people choose to engage in an activity if they have a good perception of it and important people around them approve it [22].

Perceived barriers of puerperal sepsis preventive behaviour

Pander illustrates that Perceived barriers to action are perceptions of the hurdles of undertaking health behaviour [16]. The perceived barrier is lower and most significant in correlation to health-promoting behaviour [19]. Studies have demonstrated that the anticipated hurdles impact the intention to engage in an action and its execution [22]. Literature has consistently shown that more significant perceived barriers were related to lower levels of health promotion behaviour [21]. Several studies identified that the barriers to healthy behaviours were lack of time, family and occupational responsibilities, fatigue, illness, costs, and lack of transportation and culture [21]. Several factors are responsible for constituting barriers to Health Promotion (HP) lack of confidence in the effectiveness of HP behaviour, lack of time, lack of patient motivation, lack of skill, cost-effectiveness, infrastructural barriers, lack of support and lack of collaboration between discipline [42].

Postpartum social support

When people feel that their family and/or relatives routinely expect and encourage them to practice those actions, they are more likely to engage in beneficial health promotion behaviours [21]. More pregnant women adopt health-promoting activities as a result of increased social support. Additionally, social support may decrease adverse psychological complications and consequences, such as injury, illness and limitations, as a result of consequent improvement in people’s health and quality of life [19]. Supportive behaviours that may drive increases in positive attitude include seeking guidance, avoiding negative support, such as criticism, and increasing positive support, such as praise from family and friends [21]. Studies indicated that women with more social support tended to have more frequent prenatal care visits [23].

Health-promoting behaviours

Studies have shown that women with high self-efficacy and perceived benefits are more likely to receive positive social support and are, therefore, more likely to engage in health-promoting behaviours. Positive effects come through perceived benefits and social support for adopting health-promoting behaviours have been identified by different research [19].

Personal factors

Personal factors are individual biological, psychological, and sociocultural characteristics that influence health behaviour [16, 17]. The personal factors most strongly correlated with lower health promotion behaviour [21]. Research has shown that healthy behaviour positively and significantly correlates with family income and education. This may be due to their higher level of knowledge about healthy behaviours and their higher economic status [22].

Puerperal sepsis is one of the substantial contributing causes of maternal fatalities across the globe. It is considered the 3rd leading cause of maternal death, given its prevalence rate. Modifiable determinants of puerperal sepsis have been identified through several research studies; knowledge, the inadequacy of health facilities, and healthcare provider implementation of the standard guidelines are among the more noteworthy ones. Dynamics elements are influential in carrying out puerperal sepsis preventive behaviour among postnatal mothers during puerperium. There is a need to implement the health promotion theory to promote puerperal sepsis preventive behaviour, keeping in mind that individuals ought to adapt behaviour when they treasure trove it beneficial to them.

Materials and methods

This section outlines the suggested strategy of this experiment and the methods used to identify the factors influencing health promotion behaviour on puerperal sepsis among postpartum mothers.

A descriptive correlational study was conducted in a tertiary-level hospital in Dhaka City, Bangladesh, between July 2022 and June 2023. The G-power analysis determined the sample size, which set a significance level of 0.05, a power of 0.80 and an effect size of 0.30, yielding a total sample size of 112. The technique of convenience sampling was used to recruit postpartum mothers based on the following inclusion criteria: (a) The 6–8 weeks postpartum mother visited the EPI clinic/centre during the data collection period, and (b) Willing to take part in this study.

A structured questionnaire identified perceived benefits, barriers, postpartum social support, and puerperal sepsis preventive behaviour among postpartum mothers. A total of 67 items took about 15–20 min. Researchers developed the Demographic Structural Interviewing Questionnaire to collect the participants’ sociodemographic and pregnancy-related information. The Perceived Benefits of Puerperal Sepsis Preventive questionnaire was developed by researchers from a literature review [38]. It consists of 13 items. The participants were asked to indicate their perceived benefits of puerperal sepsis preventive behaviour with a 5-point Likert scale. Higher scores indicate that postpartum mothers’ have greater perceived benefits of puerperal sepsis preventive behaviour. The Perceived Barrier to puerperal sepsis preventive behaviour questionnaire was also developed by researchers from the literature review [42] [43]. It consists of 12 items. The participants were asked to indicate their perceived barriers to puerperal sepsis preventive behaviour on a 5-point Likert scale. A higher score indicates that postpartum mothers’ have greater perceived barriers to practising puerperal sepsis preventive behaviour. The postpartum social support scale was developed by The Artemis Centre for Guidance [44]. The responses were based on a 5-point Likert scale, which included nine items. The higher score would be the high social support for puerperal sepsis preventive behaviour. The researchers developed puerperal sepsis preventive behaviour based on the literature reviewed, which included 18 items; the higher score was the high adoption of puerperal sepsis preventive behaviour [45].

The study was approved by the Institutional Review Board (IRB) of the National Institute of Advanced Nursing Education and Research (NIANER) and Bangabandhu Sheikh Mujib Medical University (BSMMU). Data collection was started after obtaining permission from the data collection setting. The purpose of the study was explained to the participants, and written consent was obtained from them. Data was collected by a structured questionnaire. The questionnaire was provided to them, and they took about 15–20 min to complete. Data was collected and analyzed by researchers using descriptive and inferential statistics. Descriptive statistics described descriptive variables, such as mean, SD, frequency, and percentage. The inferential statistics Pearson’s correlation, t-test, and ANOVA were used to describe the relationship among study variables. Regression analysis was carried out to identify the predictive variables of puerperal sepsis preventive behaviour.

Results

The socio-demographic and pregnancy-related characteristics

This correlational study included 112 participants who were convenient during data collection. The mean age of the participants was 25.04 years. Most participants completed their secondary education, which is about 50%. Most participants were Muslim 96.4% and lived in urban areas 67%. The mean family income was 22,879 Taka. About 49.1% of participants became pregnant more than 2 times and have more than two children alive. Among all the participants, 57.1% visited for antenatal check-ups at different facilities 5 to 9 times during their last pregnancy. They visited for this reason to physicians at medical colleges & other healthcare facilities, which is about 55.4%. Most of the participants delivered their child at MCH & other facilities 86.6% and delivered their child through caesarean Sect. 71.4%. During hospital admission, the participant’s amniotic membrane was intact, about 58.9%. The majority of participants suffered from labour complications 68.8%, and most of them suffered from premature rupture of membrane (PROM) 34.1%. The mean duration of labour was 5.20 h (Table 1).

Table 1.

Distribution of socio-demographic and pregnancy-related characteristics of participants (N = 112)

Variables	Categories	n	%	M ± SD
Age	(Min-Max: 18–38)			25.04 ± 5.14
Level of Education	Primary	25	22.3
	Secondary	56	50
	College and Others	31	27.7
Religion	Muslim	108	96.4
	Hindu	4	3.6
Residence	Rural	37	33
	Urban	75	67
Monthly family income (Min-max: 6.0-100.00)				22.87 ± 15.84
Gravida	1	52	46.4
	≥ 2	55	49.1
Para	1	57	50.9
	≥ 2	55	49.1
Total ANC visit	1–4	43	38.4
	> 4	69	61.6
Setting of ANC visit	Family Planning Clinic	29	25.9
	UHC& District Hospital	21	18.8
	MCH & Others	62	55.4
Place of delivery	Maternity Clinic, UHC& District Hospital	15	13.4
	MCH & Others	97	86.6
Mode of delivery	Normal	32	28.6
	Caesarean Section	80	71.4
Condition of membrane on hospital admission	Intact	66	58.9
	Ruptured	46	41.1
Labor complication	Yes	77	68.8
	No	35	31.3
If complication, which type	Prolong labor	3	3.5
	PROM	29	34.1
	Preterm labor	10	11.8
	Labor dystocia	14	16.5
	Others	29	34.1
	Missing	27	24.1
Duration of labour	(Min-Max: 2–24)			5.20 ± 5.18

Perceived benefits, perceived barriers and social support of puerperal sepsis preventive behavior of postpartum mothers

The result of perceived benefit showed that the average perceived benefits were 3.19 (SD = 0.46). More than half (55.4%) of the participants strongly agreed that using hygienic and comfortable sanitary napkin will help to prevent puerperal sepsis, 53.6% mentioned washing hand before and after perineal care can prevent puerperal sepsis, 61.6% stated identification and avoidance of source of infection is essential to prevent puerperal sepsis, 73.2% strongly opinionated postnatal exercise is vital to get back to pre-pregnant condition. Whereas only 12.5% of participants strongly mentioned checking the colour and odour of lochia for any change is required to identify puerperal infection, and 27.7% strongly agreed that practising perineal sitz bath helps prevent puerperal sepsis (Table 2).

Table 2.

The distribution of perceived benefits (N = 112)

Items	0 Strongly disagree	1 Disagree	2 Neutral	3 Agree	4 Strongly agree	M ± SD
	n (%)	n (%)	n (%)	n (%)	n (%)
Using hygienic and comfortable sanitary napkin will help to prevent puerperal sepsis.	-	1(0.9)	10(8.9)	39(34.8)	62(55.4)	3.45 ± 0.70
Timely sanitary napkin changes help to prevent puerperal sepsis	1(0.9)	1(0.9)	10(8.9)	46(41.1)	54(48.2)	3.35 ± 0.76
Clean genital and perineal area properly helps to prevent puerperal sepsis.	-	2(1.8)	10(8.9)	50(44.6)	50(44.6)	3.32 ± 0.71
Check color and odor of lochia for any change is required to identify puerperal infection.	59(4.5)	4(3.6)	68(60.7)	21(18.8)	14(12.5)	2.31 ± 0.90
Hand wash before and after perineal care can prevent puerperal sepsis.	-	1(0.9)	12(10.7)	39(34.8)	60(53.6)	3.41 ± 0.07
Practicing perineal sitz bath is helpful for preventing puerperal sepsis.	-	3(2.7)	45(40.2)	33(29.5)	31(27.7)	2.82 ± 0.08
Early identification of sign of infection is essential to manage it	-	3(2.7)	22(19.6)	52(46.4)	35(31.3)	3.06 ± 0.77
Planning and eating nutritious foods contributes to rapid wound healing during puerperium	-	-	25(22.3)	54(48.2)	33(29.5)	3.07 ± 0.72
Identification and avoidance of source of infection is essential to prevent puerperal sepsis.	-	-	5(4.5)	38(33.9)	69(61.6)	3.57 ± 0.58
Avoiding sexual activities during the first postpartum to prevent puerperal sepsis.	-	-	17(15.2)	48(42.9)	47(42)	3.27 ± 0.71
Postnatal exercise is important to get back to pre-pregnant condition	-	-	6(5.4)	24(21.4)	82(73.2)	3.68 ± 0.57
Revitalizing activities improve the quality of postnatal life.	-	-	41(36.6)	22(19.6)	49(43.8)	3.07 ± 0.09
Restriction of visitors during puerperium is way to prevent sepsis.	-	2(1.8)	20(17.9)	44(39.3)	46(41.1)	3.20 ± 0.08
Total					=	3.19 ± 0.46

The result of the perceived barrier showed an average score of 1.92 (SD = 0.96), where the majority of the participants 65.2% agreed and strongly agreed that health care personnel did not suggest to carryout perineal care and 64.3% agreed and strongly agreed health care facilities did not share standard guideline for perineal care. However, only 5.4% of participants strongly stated that their family culture inhibits them from going for postnatal check-ups. 5.4% of participants strongly agreed that they have a busy schedule with household work, inhibiting effective perineal care (Table 3).

Table 3.

The distribution of perceived barriers (N = 112

Items	0 Strongly disagree	1 Disagree	2 Neutral	3 Agree	4 Strongly agree	M ± SD
	n (%)	n (%)	n (%)	n (%)	n (%)
I am not assured about effectiveness of perineal care.	8(7.1)	52(46.4)	8(7.1)	31(27.7)	13(11.6)	1.90 ± 1.22
I have busy schedule with household work	1(0.9)	58(51.8)	24(21.4)	23(20.5)	6(5.4)	1.78 ± 0.97
I am not encouraged by family members to practice perineal care	6(5.4)	50(44.6)	13(11.6)	28(25)	15(13.5)	1.96 ± 1.20
I am not skilled to practice perineal care/ perineal hygiene	11(9.8)	47(42)	10(8.9)	30(26.8)	14(12.5)	1.90 ± 1.26
Health care personnel did not suggest that me to do so	5(4.5)	29(25.9)	5(4.5)	47(42)	26(23.2)	2.54 ± 1.23
Health care facilities not shared standard guideline for perineal care.	5(4.5)	29(25.9)	6(5.4)	46(41.1)	26(23.2)	2.53 ± 1.23
I am not aware about healthy lifestyle during postnatal period/ puerperium.	3(2.7)	44(39.3)	32(28.6)	27(24.10	6(5.4)	1.90 ± 0.09
I don’t want to change my lifestyle during puerperium.	1(0.9)	48(42.9)	55(49.1)	8(7.8)	0	1.62 ± 0.63
I am unable to change my lifestyle due to other medical condition.	6(5.4)	62(55.4)	15(13.4)	14(12.5)	15(13.4)	1.73 ± 1.17
My family culture inhibits me to go for postnatal checkup.	13(11.6)	57(50.9)	26(23.2)	10(8.9)	6(5.4)	1.46 ± 0.09
I am unable to access postnatal health care checkup and service due to distance.	7(6.3)	58(51.8)	9(8)	25(22.3)	13(11.6)	1.81 ± 1.20
My family environment is not so healthy.	5(4.5)	56(50)	12(10.7)	20(17.9)	19(17)	1.94 ± 1.26
Total					=	1.92 ± 0.52

The result of post-partum social support was an average of 4.36 (SD = 0.52), which represents strong social support; the majority of the participants, 91%, opinionated that most of the time and all the time, there is someone to take her or the baby to the doctor if needed. 89.3% of participants agreed that they have someone to count on to listen to them when they need to talk most of the time. Among 112 participants, 81.3% of postnatal mothers stated there is someone to love and make them feel special most of the time to all the time (Table 4).

Table 4.

Distribution of postpartum social support(N = 112)

Items	1 None of the time	2 A little of the time	3 Some of the time	4 Most of the time	5 All of the time	M ± SD
	n (%)	n (%)	n (%)	n (%)	n (%)
Someone you can count on to listen to you when you need to talk	4(3.6)	3(2.7)	5(4.5)	30(26.8)	70(62.5)	4.42 ± 0.97
Someone to give you good advice about a problem.	1(0.9)	6(5.4)	8(7.1)	38(33.9)	59(52.7)	4.32 ± 0.89
Someone to take you or baby to the doctor if needed	2(1.8)	1(0.9)	7(6.3)	38(33.9)	64(57.1)	4.44 ± 0.80
Someone you can laugh or relax with	2(1.8)	3(2.7)	9(8)	35(31.3)	63(56.3)	4.37 ± 0.88
Someone to help you to get information or help you to solve a problem	0	5(4.5)	11(9.8)	32(28.6)	64(57.1)	4.38 ± 0.84
Someone to help you with chores or with taking care of the baby	2(1.8)	4(3.6)	10(8.9)	27(24.1)	69(61.6)	4.40 ± 0.09
Someone to share with your most private worries and fear with	1(0.9)	7(6.3)	9(8)	35(31.3)	60(53.6)	4.30 ± 0.09
Someone to do something enjoyable with	2(1.8)	4(3.6)	15(13.4)	36(32.1)	55(49.1)	4.23 ± 0.09
Someone to love you and make you feel special	1(0.9)	3(2.7)	17(15.2)	19(17)	72(64.3)	4.41 ± 0.09
Total					=	4.36 ± 0.52

The puerperal sepsis preventive behaviour result showed that the mean score was 2.94 (SD = 0.91), which means that most of the time, participants performed puerperal sepsis preventive behaviours. The majority of them (83.9%) avoided sexual activities during the first 40 days after delivery, 83% of participants consumed prescribed antibiotics properly, most of the participants 79.5% always used hygienic and comfortable sanitary napkins, whereas least of the participants 9.8% performed postpartum exercise to regain pre-pregnancy state. The majority of the participants, 72.3%, always washed their hands before and after perineal care, and 71.4% dried their perineum well with a clean and dry towel to prevent puerperal sepsis (Table 5).

Table 5.

Distribution of puerperal sepsis preventive behavior among postnatal mothers (N = 112)

Items	0 Never	1 Rare	2 Sometimes	3 Mostly	4 Always	M ± SD
	n (%)	n (%)	n (%)	n (%)	n (%)
Using hygienic and comfortable sanitary napkin	0	3(2.7)	2(1.8)	18(16.1)	89(79.5)	3.72 ± 0.63
Avoiding delay to change sanitary napkin.	2(1.8)	3(2.7)	12(10.7)	31(27.7)	64(57.1)	3.36 ± 0.90
Planning and eating nutritious foods.	0	4(3.6)	17(15.2)	32(28.6)	59(52.7)	3.30 ± 0.86
Performing postpartum exercise to regain pre-pregnant state.	53(47.3)	21(18.8)	16(14.3)	11(9.8)	11(9.8)	1.16 ± 1.37
Performing revitalizing activities.	28(25)	22(19.6)	25(22.3)	24(21.4)	13(11.6)	1.75 ± 1.35
Seeking care from person who would supportive.	0	7(6.3)	6(5.4)	42(37.5)	57(50.9)	3.33 ± 0.84
Managing time for perineal care	0	3(2.7)	10(8.9)	50(44.6)	49(43.8)	3.30 ± 0.75
Practicing perineal sitz bath if needed.	40(35.7)	9(8)	19(17)	25(22.3)	19(17)	1.77 ± 1.54
Using clean water in lavatory/ washroom.	2(1.8)	2(1.8)	7(6.3)	25(22.3)	76(67.9)	3.53 ± 0.83
Washing hands before and after perineal care.	1(0.9)	2(1.8)	2(1.8)	26(23.3)	81(72.3)	3.64 ± 0.70
Drying the perineum well with a clean and dry towel.	2(1.8)	3(2.7)	5(4.5)	22(19.6)	80(71.4)	3.56 ± 0.84
Observing the color and odor of lochia.	11(9.8)	9(8)	24(21.4)	38(33.9)	30(26.8)	2.61 ± 1.24
Observing involution of uterus.	47(42)	17(15.2)	16(14.3)	16(14.3)	16(14.3)	1.44 ± 1.50
Avoiding sexual activities during first 40 days.	1(0.9)	0	4(3.6)	13(11.6)	94(83.9)	3.78 ± 0.60
Taking antibiotics properly if prescribed	4(3.6)	1(0.9)	4(3.6)	10(8.9)	93(83)	3.68 ± 0.08
Taking a plenty of rest during postnatal period.	2(1.8)	4(3.6)	19(17)	49(43.8)	38(33.9)	3.04 ± 0.09
Avoiding any source of infection	1(0.9)	14(12.5)	10(8.9)	43(38.4)	44(39.3)	3.03 ± 1.03
Ensuring limited visitors during postnatal period.	3(2.7)	17(15.2)	16(14.3)	30(26.8)	46(41.1)	2.88 ± 1.18
Total						2.94 ± 0.91

The relationship among sociodemographic and pregnancy-related characteristics, perceived benefits, perceived barriers and social support of puerperal sepsis preventive behavior

In the relationship among sociodemographic and pregnancy-related characteristics, perceived benefits, perceived barriers and social support of puerperal sepsis preventive behaviour, the result revealed that there was a significant relationship between participant’s age with perceived benefit (r = 0.28, p < 0.001), monthly income has a significant relationship with perceived benefit (r = 0.19, p < 0.05), perceived barrier (r = − 0.26, p < 0.001), and puerperal sepsis preventive behaviour (r = 0.24, p < 0.01). The area of residence has less puerperal sepsis preventive behaviour (r= -2.12, p = 0.03), the participants who visited antenatal check-ups 5–9 times significantly practised puerperal sepsis preventive behaviour (r = 7.15, p < 0.001). Participants have significant association with perceived barriers and total ANC visit (r = 5.80, p < 0.001), and perceived barrier and setting of ANC visit (r = 5.84, p < 0.01) revealed that participants who faced more barriers visited only family planning clinic rather than other specialised health care facilities like district and medical college hospitals which influenced puerperal sepsis preventive practice. Place of delivery is significantly associated with perceived barriers (r = 3.81, p < 0.01), which represents participants who faced more barriers to receiving care from medical college hospitals than received delivery care from UHC. As a result, there is less preventive practice of puerperal sepsis. In association with these, the labour complication types are significantly related to perceived barriers (r = 3.72, p < 0.01). (Table 6).

Table 6.

The relationship among sociodemographic and pregnancy related characteristics, perceived benefits, perceived barriers and social support of puerperal sepsis preventive behavior (N = 112)

Variables	Categories	Perceived Benefit		Perceived Barriers		Postpartum social support		Puerperal sepsis preventive behavior
		M ± SD	r/F/ t (p)	M ± SD	r/F/ t (p)	M ± SD	r/F/ t (p)	M ± SD	r/F/ t (p)
Age			0.28 (0.003)		− 0.09(0.35)		− 0.06(0.56)		0.15(0.12)
Level of Education	Primary Secondary College and others	42.88 ± 5.07 40.77 ± 5.98 42.00 ± 5.11	1.36(0.26)	21.28 ± 6.26 23.89 ± 8.24 23.03 ± 8.05	0.97(0.31)	38.20 ± 6.50 40.14 ± 6.17 38.61 ± 6.75	1.03(0.36)	53.72 ± 7.06 51.73 ± 9.02 54.23 ± 7.93	1.06(0.35)
Residence	Rural Urban	40.03 ± 6.33 42.35 ± 5.04	-2.09(0.04)	27.78 ± 7.70 20.75 ± 6.76	4.95(0.000)	41.57 ± 4.93 38.16 ± 6.77	2.72(0.01)	50.30 ± 9.70 54.13 ± 7.31	-2.12(0.03)
Monthly family income			0.19(0.05)		− 0.26 (0.006)		− 0.17(0.06)		0.24 (0.01)
Gravida	1 ≥ 2	40.81 ± 5.37 42.25 ± 5.71	-1.36(0.17)	22.58 ± 8.21 23.50 ± 7.45	− 0.62(0.53)	39.25 ± 5.04 39.32 ± 7.43	− 0.06(0.96)	52.50 ± 9.33 53.18 ± 7.43	− 0.43(0.67)
Para	1 ≥ 2	40.44 ± 5.43 42.76 ± 5.5	-2.24(0.027)	22.67 ± 8.12 23.49 ± 7.49	− 0.56(0.58)	39.53 ± 4.99 39.04 ± 7.64	0.40(0.69)	52.37 ± 9.14 53.38 ± 7.46	− 0.64(0.52)
Total ANC visit	1–4 > 4	39.85 ± 4.79 42.58 ± 5.80	-2.54(0.01)	25.93 ± 6.36 21.42 ± 9.0	3.06(0.003)	39.90 ± 6.93 38.93 ± 6.10	0.75(0.46)	49.61 ± 6.36 54.75 ± 8.78	-3.28(0.001)
Setting of ANC visit	Family planning clinic UHC& District Hospital MCH & Others	41.14 ± 5.29 41.43 ± 5.90 41.84 ± 5.67	0.16(0.85)	20.17 ± 6.60 27.48 ± 8.69 22.94 ± 7.41	5.84 (0.004)	37.55 ± 6.82 40.00 ± 4.92 39.85 ± 6.59	1.45(0.24)	54.38 ± 10.15 51.14 ± 9.14 52.74 ± 7.04	0.93(0.40)
Place of delivery	Maternity clinic UHC& District Hospital MCH & Others	40.67 ± 3.17 43.00 ± 1.00 41.65 ± 5.89	0.26(0.77)	19.42 ± 7.40 14.33 ± 2.52 23.79 ± 7.69	3.81(0.03)	36.92 ± 6.67 40.00 ± 1.00 39.56 ± 6.45	0.93(0.40)	56.58 ± 8.90 57.33 ± 9.87 52.27 ± 8.15	1.91(0.15)
Mode of delivery	Normal Caesarean Section & Others	21.16 ± 8.06 23.84 ± 7.59	-1.66(0.100)	21.16 ± 8.07 23.84 ± 7.539	-1.66(0.10)	36.50 ± 5.95 40.40 ± 6.28	-3.02(0.003)	54.28 ± 8.09 52.30 ± 8.41	1.14(0.26)
Condition of membrane on hospital admission	Intact Ruptured	41.56 ± 5.55 41.61 ± 5.68	− 0.04(0.964)	21.39 ± 7.50 25.48 ± 7.64	-2.81(0.01)	38.94 ± 5.99 39.78 ± 7.0	− 0.684(0.50)	53.79 ± 7.68 51.54 ± 9.11	1.41(0.16)
Labor complication	Yes No	41.08 ± 5.77 42.69 ± 5.04	-1.41(0.16)	23.82 ± 7.47 21.43 ± 8.33	1.51(0.13)	39.91 ± 6.43 37.91 ± 6.21	1.54(0.13)	51.87 ± 8.37 55.06 ± 7.92	-1.90(0.06)
If complication, which type	Prolong labor PROM Preterm labor Labor dystocia Others	43.00 ± 5.92 41.34 ± 5.39 41.50 ± 5.06 39.57 ± 6.12 41.90 ± 6.03	0.47(0.75)	21.33 ± 1.53 26.07 ± 6.75 18.00 ± 7.35 25.86 ± 7.42 21.41 ± 6.92	3.72 (0.01)	34.00 ± 4.58 40.59 ± 6.77 39.70 ± 2.36 41.29 ± 4.73 38.52 ± 7.22	1.25(0.30)	57.67 ± 6.35 51.79 ± 7.80 55.90 ± 8.12 49.79 ± 11.21 53.17 ± 7.60	1.16(0.34)
Duration of labour			0.08(0.40)		− 0.13(0.18)		− 0.15(0.11)		0.15(0.16)

The mean score of perceived benefit was 41.58 (SD = 5.58), the perceived barrier was 23.07 (SD = 7.79), social support was 39.29 (SD = 6.61), and puerperal sepsis preventive behaviour was 52.87(SD = 8.33). The perceived barrier mean was lower than other constructs, whereas the puerperal sepsis preventive behaviour mean was higher than others. The higher the score, the higher the preventive practice is (Table 7).

Table 7.

The distribution of perceived benefits, perceived barriers and social support of puerperal sepsis preventive behavior

	Item	Minimum	Maximum	Mean ± SD
Perceived Benefit	13	28.00	52.00	41.58 ± 5.58
Perceived Barriers	12	10.00	39.00	23.07 ± 7.79
Social Support	9	13.00	45.00	39.29 ± 6.41
Puerperal Sepsis Preventive Behavior	18	27.00	71.00	52.87 ± 8.33

Correlation among perceived benefits, perceived barriers and social support of puerperal sepsis preventive behavior

The result revealed that there was a significant positive relationship between perceived benefit and puerperal sepsis preventive behaviour. Participants with high perceived benefits of puerperal sepsis preventive behaviour practised more puerperal sepsis preventive behaviour (r = 0.62, p < 0.001). In contrast, it was also found that there was a significant negative association between perceived barriers and puerperal sepsis preventive behaviour. High perceived barrier (r = − 0.39, p < 0.001) was related to less puerperal sepsis preventive behaviour (r = − 0.556, p = < 0.001) among participants, and there was no significant association between postpartum social support and puerperal sepsis preventive behaviour (r = 0.14, p = 0.130) (Table 8).

Table 8.

Correlation among perceived benefits, perceived barriers and social support of puerperal sepsis preventive behavior

Variables	Perceived benefit	Perceived Barriers	Social Support	Puerperal sepsis preventive behavior
	r(p)	r(p)	r(p)	r(p)
Perceived benefit	1
Perceived barriers	− 0.392 (0.000)	1
Social support	0.003(0.978)	183(0.053)	1
Puerperal sepsis preventive behavior	0.618(0.000)	− 0.556(0.000)	0.144(0.130)	1

Linear logistic regression analysis examined the predictive variables for puerperal sepsis preventive behaviour. The R² value of 0.50 revealed that the predictor variable explained 50% variance in the outcome variable with F = 53.96, p < 0.01. The findings revealed that perceived benefit positively predict (β = 0.47, p < 0.01) and perceived barrier negatively predict (β=-0.37, p < 0.01) puerperal sepsis preventive behavior (Table-9)

Table 9.

Linear regression analysis for variable predicting Puerperal sepsis preventive behavior

Variable			95% CI
	Beta	SE	LL	UL	Β	P
Perceived Benefit	0.71	0.11	0.49	0.92	0.47	0.000
Perceived Barrier	− 0.40	0.08	− 0.55	− 0.24	− 0.37	0.000

R² = 0.50

Discussion

Sociodemographic and pregnancy-related characteristics

The mean age of the participants was 25.04 years (SD = 5.14). This result is consistent with another study conducted in Ethiopia and Egypt [7, 38]. Half (50%) of the participants completed their secondary education. This contradicts the results of another study, which found that more than half of the participants had completed secondary education [38]. The majority of the participants were Muslim (96.4%), and almost two-thirds (67%) of the participants lived in urban areas. It follows the line of another study conducted in Bangladesh, which revealed that more than half of the participants live in urban areas [10]. The mean family income was 22879 Taka (SD = 15847). Nearly half (49.1%) of participants became pregnant more than 2 times and had children more than 2. More than half (57.1%) visited for antenatal check-ups at different facilities 5–9 times during their last pregnancy. In contrast, more than half (55.4%) of participants received antenatal care at Medical College Hospital and other healthcare facilities. It is consistent with the study “Effectiveness of Puerperal Sepsis Self-Care Guideline on Women’s Health during Puerperium”, which found that more than half of the participants were multipara and attended antenatal check-ups 1–5 times [39]. Over two-thirds (86.6%) of participants delivered their baby to MCH and other healthcare facilities. Almost two-thirds (71.4%) of mother delivered their child through the caesarean section. More than half (58.9%) of the participants were admitted to the hospital with intact amniotic membranes, and more than half (68.8%) participants suffered from labour complications. This finding contradicts the study, which found that more than half of the participants had no medical or obstetric complications [39]. More than one-third (34.1%) of the participants suffered from premature rupture of membrane (PROM) during labour, and the mean duration of labour was 5.20 h.

Health promotion model and puerperal sepsis preventive behavior

In perceived benefit, the majority of the participants (55.4%) perceived that using hygienic and comfortable sanitary napkins will help to prevent puerperal sepsis, more than half (53.6%) of the participants perceived washing hands before and after perineal care can prevent puerperal sepsis, almost two-thirds (61.6%) stated identification and avoidance of source of infection is essential to prevent puerperal sepsis. Near about two-third (73.2%) of participants strongly believed that postnatal exercise is important to get back pre-pregnant condition. Whereas less than one-third (12.5%) of participants mentioned checking the colour and odour of lochia for any change is required to identify puerperal infection, and nearly one-third (27.7%) strongly agreed that practising perineal sitz bath helps prevent puerperal sepsis. The mean score of perceived benefit was 3.91. This is supported by a study conducted in Thailand, which found that high perceived benefits are strongly associated with health-promoting behaviour. It illustrates pregnant women who believed that adopting healthier habits would help their pregnancy spent additional resources and time on better pregnancy outcomes [23].

In perceived barrier, the majority of the participants (65.2%) agreed and strongly agreed that healthcare personnel did not suggest carrying perineal care during the postnatal period, more than half (64.3%) agreed and strongly agreed that healthcare facilities did not share standard guideline for perineal care. However, less than one-tenth (5.4%) of participants strongly stated their family culture inhibits them from going for postnatal check-ups. On the other hand, less than one-tenth (5.4%) of participants strongly agreed that they have a busy schedule with household work, which inhibits them from performing effective perineal care. The mean score of perceived barriers was 1.92. This finding reveals that perceived barriers influence postnatal mothers to engage in puerperal sepsis preventive behaviour. It goes with the line of a study conducted in Thailand on factors and health-promoting behaviours that influence maternal and infant outcomes in older pregnant Thai women, which found that perceived barriers are also associated with health-promotion behaviour [23].

In postpartum social support, more than two-thirds (91%) of participants strongly believe that there is someone to take their baby to the doctor from most of the time to all the time. More than two-thirds (89.3%) of the participants agreed that they have someone to count on to listen to them when they need to talk most of the time. More than two-thirds (81.3%) of the participants stated there is someone to love and make them feel special most of the time. The mean score of postpartum social support was 4.36. So, the postpartum social support among the participants of this study was relatively high. This result corresponds with another study’s findings that social support can foster health-promoting behaviour [23].

In this study, the mean puerperal sepsis preventive behaviour score was 2.94. The majority of the participants (83.9%) avoided sexual activities during the first 40 days after delivery, whereas less than one-third (16.1%) participants were unable to do so. It contradicts another study conducted in Bangladesh [10]. Over two-thirds (83%) of the participants properly consumed prescribed antibiotics. Most participants (79.5%) always used hygienic and comfortable sanitary napkins, whereas less than one-third (9.8%) of participants performed postnatal exercise to regain their pre-pregnancy state. Almost two-thirds (72.3%) of participants washed their hands before and after perineal care. This is consistent with another study conducted in Bangladesh, which found that maintaining perineal hygiene is essential to prevent puerperal sepsis [10]. It is also coherent with the study conducted to find out the factors influencing puerperal Sepsis among mothers attending the Pallisa Hospital maternity ward, which revealed that more than half of the mothers washed their hands to prevent puerperal sepsis. About two-thirds (71.4%) of participants dried their perineum well with a clean and dry towel to prevent puerperal sepsis [28]. The total mean of puerperal sepsis preventive behaviour was 2.94, representing moderately high preventive behaviour of puerperal sepsis among postnatal mothers. These results correspond with another study conducted in Thailand, which revealed high health-promoting behaviour among participants who have a lower risk of pregnancy-related complications [23].

All the constructs of the HPM are statistically significant when compared with participants’ sociodemographic and pregnancy-related characteristics. It can be indicated that perceived benefits, perceived barriers, and postpartum social support are the most essential factors of puerperal sepsis preventive behaviour among postpartum mothers. Those who perceived the benefits of puerperal sepsis preventive behaviour faced fewer barriers to practising and accessing postpartum services and practised puerperal sepsis preventive behaviour.

Socio-demographic and pregnancy-related characteristics association with health promotion model constructs

The analysis of this study showed that sociodemographic characteristics, such as age, monthly income, area of residence, number of antenatal check-ups, place of delivery, and labour complications, are significantly associated with Health Promotion Model constructs. The mean age of the participants was 25.04, within the age range of 18–38. This result is similar to a study conducted in Egypt, which identified self-care guidelines’ effectiveness in preventing puerperal sepsis [39]. Monthly family income was identified as a significant parameter for perceived benefits of puerperal sepsis preventive behaviour (p < 0.05), perceived barrier (p < 0.00) and puerperal sepsis preventive behaviour (p < 0.01). It is supported by a study conducted in Ethiopia, which found that mothers living with less family income are more likely to develop puerperal sepsis [38]. It also comes with the line of a study that found puerperal sepsis is significantly higher among mothers of low socio-economic status [11].

In this current study, the area of residence and puerperal sepsis preventive behaviour was examined. The correlational analysis found less puerperal sepsis preventive behaviour among participants of rural residence (33%), which is significant (p = 0.03). It is supported by the study, which found that the area of residence is significantly associated with the prevalence of puerperal sepsis [31], in contrast to another study conducted in Bangladesh with the current study, which did not find such a significant relationship [10]. The findings of this study also revealed that the number of antenatal check-ups has a strong association with puerperal sepsis preventive behaviour among postnatal mothers. Mothers who visited for antenatal check-ups 5–9 times (57.1%) practised more puerperal sepsis preventive behaviour (p < 0.001), and it also has a significant association with perceived barriers (p < 0.001). This finding is consistent with a study conducted in Ethiopia, which reported that mothers who visited more for antenatal checkups are less likely to develop puerperal sepsis [31].

The setting of ANC visits is relatively significant, with perceived barriers (p < 0.01) found substantial in this study. The place of delivery and perceived barriers were investigated in this current study, which was found significant (p < 0.01). There was a significant association between labour complications and perceived barriers (p < 0.01) in this correlational study.

Association of health promotion model constructs

This study statistic shows high perceived benefits of puerperal sepsis preventive behaviour results in the high practice of puerperal sepsis preventive behaviour (p < 0.001). The high perceived barrier is responsible for less puerperal sepsis preventive behaviour (p < 0.001). This finding is consistent with another study, which found that perceived benefit, perceived barrier and social support have a significant relationship (p < 0.05) with health promotion behaviour [19]. It also goes with the line of another study, which portrays that perceived barriers influence the intention and performance of health-promotive behaviour [22]. This study reveals a significant negative correlation (r = − 0.556, p < 0.001) between the perceived barriers and puerperal sepsis preventive behaviour. It is supported by a study conducted on Predictors of Health-Promoting Lifestyle in Pregnant Women Based on Pender’s Health Promotion Model, which found health promotion lifestyle has a significant and negative correlation with perceived barriers [19]. However, this study did not find any significant relationship between postpartum social support and puerperal sepsis preventive behaviour (p = 0.130). This is inconsistent with another study that found a significant relationship between social support and health-promoting behaviour [23]. This contrasts with another study that found that individuals perceived benefits and were supported by others regarding a behaviour supposed to do that [22].

Logistic regression found two significant predictors for puerperal sepsis preventive behaviour. Perceived benefits of puerperal sepsis preventive behaviour were found to be more significant in this study, which represents postpartum mothers who perceived the activities will help to obtain the optimum condition of health tend to practice more preventive behaviour of puerperal sepsis. It is consistent with the result of a study that found the perceived benefit of the action is obvious to motivate a person’s behaviour [18].

Conclusion

This study found that perceived barriers and benefits have a profound influence on health promotion behaviour for the prevention of puerperal sepsis among postpartum mothers. Postnatal mothers who face more barriers are less likely to adopt health promotion activities for the prevention of puerperal sepsis. Nonetheless, postnatal mothers who perceived the benefits of health promotion behaviour practised more puerperal sepsis preventive activities. To increase their adoption of health promotion activities and modify their lifestyle, this study suggests boosting prenatal care and postpartum health education programs and removing obstacles through strategic planning by related authorities.

Postpartum health education can change the lifestyle of mothers, which has a positive outcome in maternal and child health. A strategy should be developed to increase coverage through awareness campaigns for targeted age groups to reduce the prevalence of puerperal sepsis and increase perception regarding preventive practice benefits. Healthcare providers should reflect the standard guidelines during ANC to implement more preventive practices during postpartum.

Healthcare authorities may strengthen the follow-up schedule for postpartum through proper monitoring. An adequate staffing pattern is required for the evaluation of postnatal service. Nurses must be engaged in care monitoring and evaluation of effective postnatal care. Findings may recommend further experimental study to develop and assess the effect of health promotion guidelines on puerperal sepsis.

Abbreviations

PP

Puerperal sepsis

HP

Health promotion

HPM

Health promotion model

EPI

Expanded programme of immunization

DMCH

Dhaka medical college hospital

ANC

Antenatal checkup

MCH

Medical college hospital

WHO

World health organization

HIV

Human immune deficiency virus

AIDS

Acquired immune deficiency syndrome

TB

Tuberculosis

Author contributions

The study was conceptualized and designed by SA and FK, who also had complete access to all the study’s data and assumed responsibility for the validity of the model generation and the study’s data. The article was written with cooperation from all of the contributors. FA, RK and SKD contributed to the critical revision of the report. SA, FK, CH and AA developed all the results and data presentation methods. The final version has been reviewed and approved by all authors, who also contributed to the data collection and analysis.

Funding

None.

Data availability

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study was approved by the Institutional Review Board of the National Institute of Advanced Nursing Education and Research (IRB NO.EXP.NIA-S162)). Written informed consent was obtained from every participant. Strict ethical standards and procedures were adhered to, and the anonymity of the participants was ensured. Written informed consent was obtained.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.