Vaginal Colonization and Neonatal Infections in Central Uganda : Etiology, Antimicrobial Resistance and Associated Factors

Bakgrunn: Bakterier som koloniserer fødselskanalen til fødende kvinner kan overføres til deres nyfødte, og noen av dem kan dermed utvikle tidlige infeksjoner. Infeksjon i navlestrengstumpen (omfalitt) er en viktig risikofaktor for neonatal sepsis. Pga. utbredt antimikrobiell resistens kan behandling av nyfødtsepsis være utfordrende. Vi trenger oppdatert informasjon om forekomst av infeksjoner med resistente bakterielle patogener som kan overføres fra fødende kvinner til deres nyfødte babyer. Målet med denne avhandlingen er å beskrive potensielt patogene bakterier som koloniserer skjeden til fødende kvinner og navlestrengstumpene til de av deres nyfødte som får omfalitt, samt å karakterisere bakteriene som forårsaker neonatal sepsis i og i nærheten av Kampala i Uganda. Metoder: Mellom juli 2016 og juli 2018 gjennomførte vi to tverrsnittstudier (artikkel I og II), der vi samlet inn vaginale prøver fra fødende kvinner ved tre helseklinikker i og nær Kampala, og en prospektiv kohortstudie (artikkel III) av deres nyfødte som vi fulgte i 4 uker og tok bakteriologiske prøver fra navlestrengstumpen deres når de fikk omfalitt. Vi gjennomførte også en annen tverrsnittstudie (artikkel IV) der vi studerte sykehusinnlagte spedbarn opp til og med 4 ukers alder som hadde kliniske tegn på sepsis. Vi dyrket bakterier fra fødselskanals- og navlestrengstumpen (artikkel I, II og III) samt fra blod (artikkel IV). I tillegg utførte vi polymerasekjedereaksjon for å identifisere methicillinresistente Staphylococcus aureus (MRSA). Bakteriestammer som viste resistens mot antibiotika fra minst 3 ulike antibiotikaklasser betraktet vi som multiresistente. Resultater: Vi rekrutterte 1472 fødende kvinner med en gjennomsnittsalder på 25 år. Nihundreogfemtifem (65%) av kvinnene hadde potensielt patogene bakterier i sin fødselskanal (artikkel I). De mest vanlige var Escherichia coli (35%), Klebsiella pneumoniae (10%) og Staphylococcus aureus (8%). Av de 1472 kvinnene var 57 (4%) kolonisert med utvidet-spektrum beta-laktamase (ESBL)-produserende bakterier, 45 (3%) med MRSA, og 27 (2%) med karbapenem-resistente Enterobacteriaceae (artikkel II). Totalt 750 (51%) av de 1472 kvinnene hadde multiresistente potensielt patogene bakterier i sin fødselskanal. Vi fulgte opp 769 av barna født ved klinikkene i 2-årsperioden fra juli 2016, og nesten 10% av dem utviklet omfalitt i første levemåned (artikkel III). De dominerende potensielt patogene bakteriene hos disse 65 babyene var E. coli (28%), K. pneumoniae (11%) og Citrobacter freundii (8%). I sykehusstudien fant vi at 46 (13%) av de 359 nyfødte med kliniske tegn på sepsis hadde positiv blodkultur (artikkel IV). De dominerende patogenene blant disse barna var S. aureus (63%), E. coli (15%) og K. pneumoniae (11%). Mange av disse bakteriene var resistente mot ampicillin, gentamicin, ceftriaxon og/eller methicillin. Konklusjon: I de tre studieklinikkene var E. coli og K. pneumoniae de to vanligste bakterieartene isolert fra fødende kvinners fødselskanal. Disse var også de to vanligst isolerte artene hos studiebarn med omfalitt. I vår studie utviklet nesten 10% av babyene omfalitt i løpet av den første levemåneden. En betydelig andel av de potensielt patogene bakteriene fra kvinnenes fødselskanal og fra babyenes navlestrengstump samt av de som ble dyrket fra blodet til de nyfødte innlagt i sykehus med klinisk sepsis var resistente mot ampicillin, gentamicin og/eller ceftriaxone, antibiotika som inngår i førstelinjebehandlingen av nyfødtsepsis. Antibiotikaresistens kan se ut til å være et betydelig problem også i sentrale deler av Uganda, og tiltak for å begrense utbredelsen vil være avgjørende for rasjonell behandling av alvorlige bakterielle infeksjoner hos disse nyfødte barna.Background: Bacteria colonizing the birth canal of women in labor may be passed to their babies during birth, and some of them thereby develop infections. Umbilical cord stump infection (omphalitis) is an important risk factor for neonatal sepsis. Neonatal sepsis can be difficult to treat with commonly available antibiotics because antimicrobial resistance is widespread. Therefore, there is need to generate updated information about the prevalence and risk factors for infections with resistant bacterial pathogens that may be vaginally transmitted to neonates during birth. The aim of this thesis was to describe the bacteriological profile of potential pathogens colonizing the vagina of women in labor and the umbilical stumps of their newborns as well as the bacteriological profile of pathogens causing neonatal sepsis in Kampala and Mukono districts in central Uganda. Methods: We conducted two cross-sectional studies (papers I and II) in which we collected vaginal swabs from women in labor and a prospective cohort study (paper III) in which we collected umbilical swabs from their neonates at three primary health care facilities in and near Kampala between July 2016 and July 2018. The neonates in the study were followed-up on days 3, 7, 14 and 28. We also conducted another cross-sectional study (paper IV) in which we studied neonates with symptoms and signs of sepsis at the pediatric emergency care unit of Mulago hospital, a tertiary referral hospital in Kampala. We performed culture and antimicrobial susceptibility testing on all study specimens, including vaginal swabs, umbilical swabs and blood. In addition, we performed polymerase chain reaction to identify methicillin resistant Staphylococcus aureus (MRSA) isolates. Multidrug resistant bacteria were defined as bacteria resistant to antibiotics from ≥ 3 antibiotic classes. We estimated the factors associated with i) vaginal colonization with potentially pathogenic bacteria, ii) vaginal colonization with antimicrobial resistant bacteria, iii) omphalitis and iv) culture-positive neonatal sepsis. Results: We recruited 1,472 women in labor with a mean age of 25 years (paper I and II). Nine hundred and fifty five of the women (65%; 95% confidence interval [CI] 62% to 67%) were vaginally colonized with potentially pathogenic bacteria. The most commonly isolated potentially pathogenic bacteria from women in labor were Escherichia coli (35%), Klebsiella pneumoniae (10%) and Staphylococcus aureus (8%). Of the 1,472 women, 57 (4%) were colonized with extended-spectrum beta-lactamase (ESBL)-producing bacteria, 27 (7%) were colonized with carbapenem-resistant Enterobacteriaceae and 45 (3%) were colonized with MRSA (paper II). A total of 750 of the 1472 women (51%) had multidrug resistant potentially pathogenic bacteria. We followed up 769 of the children born at the clinics in the 2-year period from July 2016, and almost 10% of them developed omphalitis in the first month of life (Article III). The predominant potentially pathogenic bacteria isolated from the 65 babies with omphalitis were E. coli (28%), K. pneumoniae (11%) and Citrobacter freundii, (8%). In the hospital study, we found that 46/359 (13%; 95 % CI 10%, 17%) of the babies with clinical signs of sepsis had a positive blood culture (paper IV). The predominate pathogens among the 46 neonates with clinical signs of sepsis and a positive blood culture were S. aureus (63%), E. coli (15%) and K. pneumoniae (11%). Many of these bacteria were resistant to ampicillin, gentamicin, ceftriaxone and/or methicillin. Conclusion: In the three study clinics, E. coli and K. pneumoniae were the two most common bacterial species isolated from the birth canal of women in labor. These were also the two most frequently isolated potential pathogens among study babies who developed omphalitis. Further studies to explore the link between colonization of the birth canal and subsequent neonatal infections are necessary. Neonatal infections were common with almost 10% developing omphalitis in the first month of life. A substantial proportion of the potential pathogens isolated from the birth canal of women and the umbilical cord stumps of their babies as well as those grown in blood from hospitalized babies with sepsis were resistant to ampicillin, gentamicin and ceftriaxone; common antibiotics used in treating serious neonatal infections. The observed resistance profiles indicate a problem of antimicrobial resistance, which complicates treatment of neonatal infections.Doktorgradsavhandlin

Vaginal colonisation of women in labour with potentially pathogenic bacteria: A cross sectional study at three primary health care facilities in Central Uganda

Background: Potentially pathogenic bacteria that colonise the lower genital tract of women in labour can be passed to the baby during birth. While many babies become colonised with these bacteria after delivery, a few develop neonatal infections. The lower genital tract is a reservoir for potential pathogens and a source of infection for neonates. We determined the prevalence of vaginal colonisation of potentially pathogenic bacteria among women in labour in Central Uganda and identified potential risk factors associated with this colonisation. Methods: We conducted a cross sectional study at three primary health care facilities and collected vaginal swabs from HIV-1 negative women in labour. Specimens were cultured on different selective microbiological media, and biochemical tests were used to classify bacterial isolates on the species level. Multivariable logistic regression analyses were used to estimate the association between relevant exposures and colonisation with potentially pathogenic bacteria. Results: We recruited 1472 women in labour whose mean age was 24.6 years (standard deviation [SD] 4.9). Of these, 955 (64.9%; 95% Confidence Interval [CI] 62.4, 67%) were vaginally colonised with at least one potentially pathogenic bacterial species. The most commonly isolated species were Escherichia coli (n = 508; 34.5%), Klebsiella pneumoniae (n = 144; 9.8%) and Staphylococcus aureus (n = 121; 8.2%). Results from exploratory multivariable regression analyses indicated that having had ≥5 previous pregnancies (adjusted odds ratio [aOR] 0.59; 95% CI 0.35, 0.97) or being ≥30 years old (aOR 1.52; 95% CI 1.03, 2.23) could be associated with vaginal colonisation with any potentially pathogenic bacteria, as well as with vaginal colonisation with S. aureus (aOR 0.33; 95% CI 0.12, 0.88, and aOR 2.17; 95% CI 1.17, 4.00, respectively). Possession of domestic animals in a household (aOR 0.57; 95% CI 0.35, 0.92) could be associated with vaginal colonisation with E. coli. Conclusions: Two-thirds of HIV-1 negative women in labour were vaginally colonised by potentially pathogenic bacteria, mainly E. coli, K. pneumoniae, and S. aureus.publishedVersio

Umbilical Cord Stump Infections in Central Uganda: Incidence, Bacteriological Profile, and Risk Factors

Umbilical cord stump infection (omphalitis) is a risk factor for neonatal sepsis and death. We assessed the incidence of omphalitis, described the bacteriological and antibiotic-resistance profile of potentially pathogenic bacteria isolated from the umbilical cord stump of omphalitis cases, and evaluated whether bacteria present in the birth canal during birth predicted omphalitis. We enrolled 769 neonates at birth at three primary healthcare facilities and followed them for 28 days with scheduled visits on days 3, 7, 14, and 28. Cox regression models were used to estimate the rates of omphalitis associated with potential risk factors. Sixty-five (8.5%) neonates developed omphalitis, with an estimated incidence of 0.095 cases per 28 child-days (95% CI 0.073, 0.12). Potentially pathogenic bacteria were isolated from the cord stump area of 41 (63.1%) of the 65 neonates with omphalitis, and the most commonly isolated species were Escherichia coli (n = 18), Klebsiella pneumoniae (n = 10), Citrobacter freundii (n = 5), and Enterobacter spp. (n = 4). The Enterobacteriaceace isolates were resistant to gentamicin (10.5%, 4/38), ampicillin (86.8%, 33/38), and ceftriaxone (13.2%, 5/38). Delayed initiation of breastfeeding was associated with an increased risk of omphalitis (aHR 3.1; 95% CI 1.3, 7.3); however, vaginal colonization with potentially pathogenic bacteria did not predict omphalitis.publishedVersio

Incidence of home delivery among women living with HIV in Lira, Northern Uganda: a prospective cohort study

Background Home delivery has been associated with mother-to-child transmission of HIV and remains high among HIV-infected women. Predictors for home delivery in the context of HIV have not been fully studied and understood in Northern Uganda. We therefore aimed to find out the incidence and risk factors for home delivery among women living with HIV in Lira, Northern Uganda. Methods This prospective cohort study was conducted between August 2018 and January 2020 in Lira district, Northern Uganda. A total of 505 HIV infected women receiving antenatal care at Lira regional referral hospital were enrolled consecutively and followed up at delivery. We used a structured questionnaire to obtain data on exposures which included: socio-demographic, reproductive-related and HIV-related characteristics. Data was analysed using Stata version 14.0 (StataCorp, College Station, Texas, U.S.A.). We estimated adjusted risk ratios using Poisson regression models to ascertain risk factors for the outcome of interest which was home delivery (which is delivering an infant outside a health facility setting under the supervision of a non-health worker). Results The incidence of home delivery among women living with HIV was 6.9% (95%CI: 4.9–9.5%). Single women were more likely to deliver at home (adjusted risk ratio = 4.27, 95%CI: 1.66–11). Women whose labour started in the night (night time onset of labour ARR = 0.39, 95%CI: 0.18–0.86) and those that were adherent to their ART (ARR = 0.33, 95%CI: 0.13–0.86) were less likely to deliver at home. Conclusion Home delivery remains high among women living with HIV especially those that do not have a partner. We recommend intensified counselling on birth planning and preparedness in the context of HIV and PMTCT especially for women who are: separated, divorced, widowed or never married and those that are not adherent to their ART.publishedVersio

Vaginal colonization with antimicrobial-resistant bacteria among women in labor in central Uganda: prevalence and associated factors

Background According to WHO ( CISMAC. Centre for Intervention Science in Maternal and Child health), the antimicrobial resistant bacteria considered to be clinically most important for human health and earmarked for surveillance include extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae, carbapenem-resistant bacteria, methicillin-resistant (MRSA) and, macrolide-lincosamide-streptogramin B -resistant vancomycin-resistant (VRSA) Staphylococcus aureus and vancomycin-resistant Enterococcus (VRE). If these bacteria are carried in the female genital tract, they may be transmitted to the neonate causing local or systemic neonatal infections that can be difficult to treat with conventionally available antimicrobials. In order to develop effective treatment strategies, there is need for updated information about the prevalence of colonization with important antimicrobial-resistant pathogens. Objective We sought to estimate the prevalence of vaginal colonization with potentially pathogenic and clinically important AMR bacteria among women in labour in Uganda and to identify factors associated with colonization. Methods We conducted a cross-sectional study among HIV-1 and HIV-2 negative women in labour at three primary health care facilities in Uganda. Drug susceptibility testing was done using the disk diffusion method on bacterial isolates cultured from vaginal swabs. We calculated the prevalence of colonization with potentially pathogenic and clinically important AMR bacteria, in addition to multidrug-resistant (MDR) bacteria, defined as bacteria resistant to antibiotics from ≥ 3 antibiotic classes. Results We found that 57 of the 1472 enrolled women (3.9% prevalence; 95% Confidence interval [CI] 3.0%, 5.1%) were colonized with ESBL-producing Enterobacteriaceace, 27 (1.8%; 95% CI 1.2%, 2.6%) were colonized with carbapenem-resistant Enterobacteriaceae, and 85 (5.8%; 95% CI 4.6%, 7.1%) were colonized with MRSA. The prevalence of colonization with MDR bacteria was high (750/1472; 50.9%; 95% CI 48.4%, 53.5%). Women who were ≥ 30 years of age had higher odds of being colonized with MDR bacteria compared to women aged 20–24 years (OR 1.6; 95% CI 1.1, 2.2). Conclusion Most of the women included in our study were vaginally colonized with potentially pathogenic MDR and other clinically important AMR bacteria. The high prevalence of colonization with these bacteria is likely to further increase the incidence of difficult-to-treat neonatal sepsis.publishedVersio

Inequity in utilization of health care facilities during childbirth: a community-based survey in post-conflict Northern Uganda

Aim To assess inequity in utilization of health care facilities during childbirth and factors associated with home births in Lira district, Northern Uganda. Subjects and methods In 2016, we surveyed 930 mothers with children under the age of 2 years in Lira district, Northern Uganda. We used multiple correspondence analysis to construct the wealth index in quintiles, based on household assets. The concentration index is the measure of socioeconomic inequality used in this article, which we calculated using the Stata DASP package. We also conducted multivariable logistic regression to assess factors associated with home births. Results A third of mothers (n = 308) gave birth from home [33%, 95% confidence interval (CI) (26%–41%)]. Giving birth at a health facility was pro-rich with a concentration index of 0.10 [95% CI (0.05–0.14)]. Upon decomposing the concentration index, the most important determinant of inequity was the mother's residence. Factors associated with home births in multivariable logistic regression included rural residence [adjusted odds ratio (AOR) 3.1, 95% CI (1.8–5.3)], precipitate labor [AOR 4.18, 95% CI (2.61–6.71)], and labor starting in the evening or at night. Mothers who had previously given birth from home were more likely to give birth at home again [AOR 40.70, 95% CI (18.70–88.61)], whereas mothers who had experienced a complication during a previous birth were less likely to give birth at home [AOR 0.45, 95% CI (0.28–0.95)]. Conclusion There was inequity in the utilization of health facilities for childbirth. Programs that promote health facility births should prioritize poorer mothers and those in rural areas.publishedVersio

"We shall count it as a part of kyogero": acceptability and considerations for scale up of single dose chlorhexidine for umbilical cord care in Central Uganda

Background: Cleansing the umbilical cord with chlorhexidine reduces neonatal morbidity and mortality, particularly in communities where newborn deaths and home births are common. As a result, the World Health Organization and national authorities are advocating the scale up of this intervention. In order for such a scale up to be effective, it has to be acceptable to the targeted population. With the overall aim to clarify conditions for scale-up, this study explored the acceptability of single dose chlorhexidine solution for umbilical cord care among health workers and infant care providers in the districts of Kampala and Mukono in Central Uganda. Methods: This was a qualitative study that involved mothers of neonates enrolled in a chlorhexidine trial, nurses implementing the trial, key community members and opinion leaders in childcare. We conducted 30 in depth interviews (IDIs) with mothers (18), health workers (8), traditional birth attendants (2), a father (1) and a grandmother (1) and 4 focus group discussions (FGDs), 3 with mothers and 1 with health workers. We used qualitative content analysis to analyze our findings and borrow upon Sekhon’s model when presenting our findings. Results: Cognitive and emotional responses to chlorhexidine use included ease of use, and a perception that chlorhexidine reduced smell and abdominal colic. We also found that wider social and cultural factors were important to chlorhexidine use. These included cultural value put on quick separation of the umbilical cord as well as the practice of bathing the baby in a herbal mixture called kyogero. We also found that older relatives were key decision makers in umbilical cord care for newborns, but were seldom present during health workers’ counseling of mothers about hygienic care of the cord. Conclusions: The application of chlorhexidine on the umbilical cord stump at birth was acceptable as an addition rather than a total replacement of traditional substances. The scale up of chlorhexidine should consider how to accommodate local beliefs and practices in a way that does not compromise the effect of the intervention; encouraging mothers to delay the bathing of babies in kyogero could be one way of doing this.publishedVersio

Efficacy of umbilical cord cleansing with a single application of 4% chlorhexidine for the prevention of newborn infections in Uganda: study protocol for a randomized controlled trial

Abstract Background Yearly, nearly all the estimated worldwide 2.7 million neonatal deaths occur in low- and middle-income countries. Infections, including those affecting the umbilical cord (omphalitis), are a significant factor in approximately a third of these deaths. In fact, the odds of all-cause mortality are 46% higher among neonates with omphalitis than in those without. Five large randomized controlled trials in Asia and Sub-Saharan Africa (SSA) have examined the effect of multiple cord stump applications with 4% chlorhexidine (CHX) for at least 7 days on the risk of omphalitis and neonatal death. These studies, all community-based, show that multiple CHX applications reduced the risk of omphalitis. Of these trials, only one study from South Asia (the Bangladeshi study) and none from Africa examined the effect of a single application of CHX as soon as possible after birth. In this Bangladeshi trial, CHX led to a reduction in the risk of mild-moderate omphalitis and neonatal death. It is important, in an African setting, to explore the effect of a single application among health-facility births. A single application is programmatically much simpler to implement than daily applications for 7 days. Therefore, our study compares umbilical cord cleansing with a single application of 4% CHX at birth with dry cord care among Ugandan babies born in health facilities, on the risk of omphalitis and severe neonatal illness. Methods The CHX study is a facility-based, individually randomized controlled trial that will be conducted among 4760 newborns in Uganda. The primary outcomes are severe illness and omphalitis during the neonatal period. Analysis will be by intention-to-treat. Discussion This study will provide novel evidence, from a Sub-Saharan African setting, of the effect of umbilical cord cleansing with a single application of 4% CHX at birth and identify modifiable risk factors for omphalitis. Trial registration ClinicalTrials.gov, identifier: NCT02606565 . Registered on 12 November 2015

Neonatal sepsis at Mulago national referral hospital in Uganda: Etiology, antimicrobial resistance, associated factors and case fatality risk

Background Sepsis is the third most common cause of death among neonates, with about 225,000 newborns dying every year globally. Data concerning the microbial etiology of neonatal sepsis and antimicrobial resistance profiles of its causative agents are necessary to inform targeted and effective treatment and prevention strategies. Objective To determine the proportion of newborns with symptoms and signs of sepsis who had a positive blood culture, its bacterial etiology, the antimicrobial resistance patterns as well as the factors associated with culture-positivity and case fatality at Mulago national referral hospital in Uganda. Methods We conducted a cross-sectional study among 359 neonates with symptoms and signs of sepsis who presented to the pediatric emergency care unit of Mulago national referral hospital from mid-January to end of December 2018. We performed blood culture and antimicrobial susceptibility testing, and conducted polymerase chain reaction to identify methicillin-resistant Staphylococcus aureus (MRSA) isolates. We used multivariable logistic regression to estimate the association between potential risk factors and culture-positive neonatal sepsis. Findings Of the 359 neonates recruited, 46 (12.8%; 95% CI 9.5%, 16.7%) had a positive blood culture. The predominant isolated bacteria were Staphylococcus aureus in 29 (63.0%), Escherichia coli in seven (15.2%), and Klebsiella pneumoniae in five (10.9%). Of the 46 pathogens, 73.9% were resistant to ampicillin, 23.9% to gentamicin and 8.7% to ceftriaxone. We isolated MRSA from the blood specimens of 19 (5.3%) of the 359 neonates, while 3 (0.8%) grew extended spectrum beta lactamase producers. The case fatality risk among neonates with neonatal sepsis was 9.5% (95% CI: 6.6%, 13.0%). Cesarean section delivery was strongly associated with culture-positive sepsis (adjusted odds ratio 3.45, 95% CI: 1.2, 10.1). Conclusion One in eight neonates with clinical signs of sepsis grew a likely causative bacterial pathogen. S. aureus was the main pathogen isolated and a third of these isolates were MRSA. A significant proportion of the isolated bacterial pathogens were resistant to the first and second line antibiotics used for the treatment of neonatal sepsis. There is need to revisit the current treatment guidelines for neonatal sepsis

Vaginal colonisation of women in labour with potentially pathogenic bacteria: A cross sectional study at three primary health care facilities in Central Uganda

Background: Potentially pathogenic bacteria that colonise the lower genital tract of women in labour can be passed to the baby during birth. While many babies become colonised with these bacteria after delivery, a few develop neonatal infections. The lower genital tract is a reservoir for potential pathogens and a source of infection for neonates. We determined the prevalence of vaginal colonisation of potentially pathogenic bacteria among women in labour in Central Uganda and identified potential risk factors associated with this colonisation. Methods: We conducted a cross sectional study at three primary health care facilities and collected vaginal swabs from HIV-1 negative women in labour. Specimens were cultured on different selective microbiological media, and biochemical tests were used to classify bacterial isolates on the species level. Multivariable logistic regression analyses were used to estimate the association between relevant exposures and colonisation with potentially pathogenic bacteria. Results: We recruited 1472 women in labour whose mean age was 24.6 years (standard deviation [SD] 4.9). Of these, 955 (64.9%; 95% Confidence Interval [CI] 62.4, 67%) were vaginally colonised with at least one potentially pathogenic bacterial species. The most commonly isolated species were Escherichia coli (n = 508; 34.5%), Klebsiella pneumoniae (n = 144; 9.8%) and Staphylococcus aureus (n = 121; 8.2%). Results from exploratory multivariable regression analyses indicated that having had ≥5 previous pregnancies (adjusted odds ratio [aOR] 0.59; 95% CI 0.35, 0.97) or being ≥30 years old (aOR 1.52; 95% CI 1.03, 2.23) could be associated with vaginal colonisation with any potentially pathogenic bacteria, as well as with vaginal colonisation with S. aureus (aOR 0.33; 95% CI 0.12, 0.88, and aOR 2.17; 95% CI 1.17, 4.00, respectively). Possession of domestic animals in a household (aOR 0.57; 95% CI 0.35, 0.92) could be associated with vaginal colonisation with E. coli. Conclusions: Two-thirds of HIV-1 negative women in labour were vaginally colonised by potentially pathogenic bacteria, mainly E. coli, K. pneumoniae, and S. aureus