Recommendation on antibiotic prophylaxis during labour for vaginal birth

WHOGuidelineCurrent editionCC BY-NC-SA 3.0 IGO

World Health Organization · 1st edition, 2025 · 62 pages

Guidance for clinicians and policy-makers on routine antibiotic prophylaxis during labour for vaginal birth

In one sentenceWHO recommends against routine antibiotic prophylaxis during labour for vaginal birth because population-level antimicrobial resistance harms outweigh benefits from reduced maternal sepsis, which had no impact on maternal mortality.

Issuer: World Health Organization
Edition: 1st edition, 2025
Audience: Obstetricians, midwives, nurses, general practitioners providing intrapartum care; guideline developers; maternal health programme managers; ministry of health officials; training institutions
Evidence: GRADE-rated recommendations from systematic review of 4 RCTs (42,846 women), modelling studies, qualitative evidence, and economic evaluations
Reviewed: 14 Oct 2026 · GMJ

Read the original on WHO Download PDF (62 pp)

Summary by GMJ Guidelines Desk•Reviewed by Prof. Giorgi Pkhakadze, MD, MPH, PhD•Record updated 14 Oct 2026•Next check Apr 2027

What this guideline says

GMJ summary

This 2025 WHO guideline recommends against routine antibiotic prophylaxis during labour for vaginal birth. The recommendation is based on evidence from four randomized trials (42,846 women) in low- and middle-income countries, primarily using single-dose oral azithromycin 2 g.

While the intervention showed small to moderate reductions in maternal infections including sepsis (RR 0.65, NNT 167), endometritis (RR 0.66, NNT 143), and wound infections, it demonstrated no effect on maternal mortality or neonatal outcomes. Critically, modelling studies projected that increased macrolide resistance in Staphylococcus aureus and Streptococcus pneumoniae would result in 9–29 times more disability-adjusted life years (DALYs) than those averted through reduced sepsis.

The guideline emphasizes strengthening infection prevention and control measures, risk-based assessment for targeted antibiotic prophylaxis when clinically indicated, and prompt diagnosis and management of infections as the preferred strategy. Azithromycin, classified as a WHO AWaRe “Watch” antibiotic, should be prioritized for antimicrobial stewardship.

Key points

For clinicians — doses and thresholds as stated in the guideline

Routine antibiotic prophylaxis during labour for vaginal birth is not recommended in any setting or context
Azithromycin 2 g single oral dose reduced maternal sepsis (RR 0.65, NNT 167) but had no effect on maternal mortality or neonatal sepsis
Modelling shows 96,000 additional DALYs from macrolide resistance in Africa versus 11,000 DALYs averted from reduced sepsis – a 9:1 negative ratio
Azithromycin-resistant S. aureus and group A Streptococcus increased transiently in maternal and neonatal samples at 6 weeks post-birth
Antibiotic prophylaxis remains indicated for operative vaginal birth, caesarean section, preterm prelabour rupture of membranes, group B Streptococcus colonization, and manual removal of placenta per existing WHO guidance
Standard infection prevention and control precautions (hand hygiene, aseptic technique, clean equipment) are the cornerstone of preventing maternal infections
Azithromycin is a WHO AWaRe "Watch" antibiotic with high resistance potential and should be prioritized for antimicrobial stewardship policies
Early-life macrolide exposure may alter gut microbiota and has been linked to increased risk of asthma, obesity, food allergies, and inflammatory bowel disease in children

Effects of antibiotic prophylaxis during labour for vaginal birth – key maternal outcomes

Table extracted from the guideline

Outcome	Trials/Women	Relative effect (95% CI)	Absolute effect per 1000	NNT	Certainty
Maternal sepsis	4/42,430	RR 0.65 (0.56–0.77)	6 fewer (8 to 4 fewer)	167	Moderate
Maternal death	4/42,371	RR 1.21 (0.63–2.33)	No effect	—	Moderate
Endometritis	2/29,973	RR 0.66 (0.55–0.78)	7 fewer (9 to 5 fewer)	143	High
Wound infection (perineal)	1/25,114	RR 0.80 (0.64–0.99)	3 fewer (5 to 0 fewer)	335	High
Neonatal sepsis	4/42,862	aRR 1.03 (0.96–1.10)	No effect	—	High
Neonatal mortality	4/42,678	aRR 1.03 (0.87–1.21)	No effect	—	High

Source: World Health Organization, Recommendation on antibiotic prophylaxis during labour for vaginal birth. Reproduced in summary form.

What changed in this edition

Versus the previous edition

First WHO recommendation specifically addressing routine antibiotic prophylaxis during labour for vaginal birth (no previous edition)
Incorporates new evidence from four RCTs (2017–2023) not available for the 2015 peripartum infections guideline
Includes modelling data on population-level antimicrobial resistance impacts, projecting regional DALY burdens from macrolide resistance in key pathogens
Explicitly addresses azithromycin's classification as a WHO AWaRe "Watch" antibiotic requiring stewardship prioritization

From the guideline

Verbatim

“The GDG concluded that the undesirable consequences of routine antibiotic prophylaxis in labour for vaginal birth outweigh the potential benefits and therefore recommended against its use.”

— World Health Organization, Recommendation on antibiotic prophylaxis during labour for vaginal birth, Section 3.2, Remarks (2025)

Editor’s perspective

Why this matters for Georgia and the region

Prof. Giorgi Pkhakadze, MD, MPH, PhD

Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration

As Chair of the Public Health Institute of Georgia and a WHO consultant, I view this guideline as critically important for our region. Georgia has made impressive strides in antimicrobial stewardship – we established national action plans on antimicrobial resistance in 2019 and have functioning surveillance systems. However, this recommendation challenges a growing international practice and requires us to resist pressure for routine intrapartum antibiotics. I would stress to Georgian obstetricians and midwives that the evidence clearly shows no maternal mortality benefit and substantial population harm through resistance – the 9:1 DALY ratio against the intervention is compelling. Our implementation priority must be strengthening infection prevention and control in maternity facilities, where hand hygiene compliance and aseptic technique offer proven, sustainable protection without resistance risks. One realistic caveat: many Georgian maternity hospitals lack consistent access to clean water and alcohol-based hand rub, so we must invest in these fundamentals before we can credibly discourage antibiotic prophylaxis as a substitute for proper infection control.

ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 14 Oct 2026

Applicability

Georgia and the South Caucasus

For Georgia and the South Caucasus, this guideline is directly applicable. The recommendation against routine antibiotic prophylaxis applies universally, regardless of local maternal sepsis rates. National programmes should prioritize strengthening infection prevention and control in maternity facilities, ensuring access to clean water, hand hygiene products (alcohol-based hand rub), and sterilization of instruments. Georgia’s antimicrobial resistance surveillance capacity and antibiotic stewardship programmes in maternity hospitals would need assessment and strengthening to monitor appropriate antibiotic use. Existing protocols should be reviewed to ensure antibiotics are prescribed only for established indications (operative vaginal birth, caesarean section, preterm prelabour rupture of membranes). Midwifery regulatory frameworks should support targeted antibiotic administration when clinically indicated while preventing routine use.

Questions this guideline answers

Quick answers

Why is routine antibiotic prophylaxis not recommended if it reduces maternal sepsis?

While azithromycin reduced maternal sepsis by 35% (NNT 167), it had no effect on maternal mortality or neonatal outcomes. Modelling shows the population-level harm from increased antimicrobial resistance (96,000 DALYs in Africa) far outweighs the benefit from reduced sepsis (11,000 DALYs averted) – a 9:1 negative ratio. The undesirable effects outweigh the benefits.

When should antibiotics still be given during labour?

Antibiotic prophylaxis remains indicated for: operative vaginal birth (vacuum, forceps), caesarean section, preterm prelabour rupture of membranes, group B Streptococcus colonization, manual removal of placenta, and third- or fourth-degree perineal tears, as per existing WHO recommendations. This recommendation only addresses routine use without clinical indication.

What are the main strategies to prevent maternal infections instead of antibiotics?

Standard infection prevention and control measures: hand hygiene according to WHO's 5 Moments; aseptic technique for all procedures; clean and sterile instruments and supplies; personal protective equipment; clean birth environment with safe water and sanitation; clinical monitoring for early detection of infection; and prompt treatment when infection is identified.

How long do azithromycin resistance effects persist after intrapartum use?

Trial data showed increased azithromycin-resistant S. aureus in maternal nasal samples at day 7, 6 weeks, and 3 months, but not at 6 and 12 months. However, modelling and follow-up studies from mass drug administration suggest resistance can persist in communities for 3.5+ years through transmission to unexposed individuals, including macrolide-resistant S. pneumoniae in children born after the intervention ended.

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