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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 15  |  Page : 24-30

Prevalence of urinary tract infections and risk factors among pregnant women attending antenatal clinics in government primary health-care centers in Akure, Nigeria


Biology Department, Federal University of Technology, Akure, Ondo State, Nigeria

Date of Submission08-Mar-2019
Date of Acceptance30-Dec-2019
Date of Web Publication11-May-2020

Correspondence Address:
Dr. Iyabo Adepeju Simon-Oke
Biology Department, Federal University of Technology, PMB 704, Akure, Ondo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/nnjcr.nnjcr_18_19

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  Abstract 


Background: Urinary tract infection (UTI) has become the most common bacterial infection in humans, both at the community and hospital settings. It has been reported in all age groups and in both sexes. This is also a leading cause of Gram-negative sepsis in hospitalized patients. This study was carried out to identify and evaluate the associated risk factors of UTIs in relation to the sociodemographic characteristics among pregnant women in the study area. Materials and Methods: A cross-sectional study was conducted from February to June, 2018, on the urine of pregnant women, and the sociodemographic information of the women was collected. A total of 300 clean midstream urine samples were collected, and a general urine microscopic examination and culture were carried out. Results: Out of the 300 urine samples cultured, 183 (61.0%) yielded significant growth of urinary pathogens, whereas 117 (39.0%) yielded either insignificant growth or no growth of any urinary pathogen. Prevalence of UTI was statistically significantly associated with the type of toilet used, symptoms of UTI, and previous history of UTI (P < 0.05). Conclusion: This study justifies that pregnant women are at high risk of UTI; therefore, screening of pregnant women during antenatal clinics should be considered very important to avoid complications. Health education with regular antenatal and personal hygiene is recommended as a precautionary measure to UTI.

Keywords: Pregnant women, questionnaire, sociodemographic, urinary tract infection, urine


How to cite this article:
Simon-Oke IA, Odeyemi O, Oniya M. Prevalence of urinary tract infections and risk factors among pregnant women attending antenatal clinics in government primary health-care centers in Akure, Nigeria. N Niger J Clin Res 2020;9:24-30

How to cite this URL:
Simon-Oke IA, Odeyemi O, Oniya M. Prevalence of urinary tract infections and risk factors among pregnant women attending antenatal clinics in government primary health-care centers in Akure, Nigeria. N Niger J Clin Res [serial online] 2020 [cited 2020 May 30];9:24-30. Available from: http://www.mdcan-uath.org/text.asp?2020/9/15/24/284081




  Introduction Top


Urinary tract infection (UTI) is an infection caused by the presence and growth of microorganisms in the urinary tract. It is usually caused by bacteria from the digestive tracts, which climb the opening of the urethra and begin to multiply to cause infection.[1] It has been reported in all age groups and in both sexes.[2],[3] In contrast to men, women are more susceptible to UTI, and this is mainly due to short urethra, absence of prostatic secretion, pregnancy, and easy contamination of the urinary tract with fecal flora.[4] Typical symptoms associated with UTI include the triad of dysuria (painful urination), urgency (the enhanced desire to void the bladder), and frequency (increased rate of urination).[5]

UTI in pregnancy is associated with significant morbidity for both mother and baby. The combination of mechanical, hormonal, and physiologic changes during pregnancy contributes to significant changes in the urinary tract, which has a profound impact on the acquisition and natural history of bacteriuria during pregnancy.[6]

UTIs are the most frequent bacterial infection in women.[7] They occur most frequently between the ages of 16 and 35 years, with 10% of women getting an infection yearly and more than 40%–60% having an infection at some point in their lives.[8] These infections complicate up to 20% of pregnancies and are responsible for the majority of antepartum admissions to the maternal–fetal medicine units.[9]

However, as with many community-acquired infections, antimicrobial resistance among the pathogens that cause UTIs is increasing and is a major health problem in the treatment of UTI.[10] There is growing concern regarding antimicrobial resistance worldwide, particularly to Entamoeba coli which is the dominant causative agent of UTI in pregnant women.[11]

Due to several anatomical and hormonal changes, pregnant women are more susceptible to develop UTI. Perhaps, if untreated, it can lead to serious obstetric complications and poor maternal and prenatal outcomes, for example, intrauterine growth restriction, preeclampsia, cesarean delivery, and preterm deliveries. Furthermore, it has been observed that asymptomatic bacteriuria can lead to cystitis and pyelonephritis, which can lead to acute respiratory distress, transient renal failure, sepsis, and shock during pregnancy.[12]

Treatment of UTIs cases is often started empirically, and therapy should be based on information determined from the antimicrobial resistance pattern of the urinary pathogens.[12] However, a large proportion of uncontrolled antibiotic usage has contributed to the emergence of resistant bacterial infections.[13] As a result, the prevalence of antimicrobial resistance among urinary pathogens has been increasing worldwide.

The emergence of antibiotic resistance in the management of UTIs is a serious public health problem, particularly in the developing world where apart from the high level of poverty, ignorance, and poor hygiene practices, there is also a high prevalence of fake and spurious drugs of questionable quality in circulation.[14] Hence, the changing spectrum of microorganisms involved in UTIs and emergence of resistance across institutions and geographical areas have made imperative the conduct of antibiotic susceptibility testing study of UTI pathogens in various regions from time to time.[15]


  Materials and Methods Top


Study area

The study was conducted at the antenatal wards in four primary health-care centers, namely Basic Health Centre Ogbese, Comprehensive Health Centre Algon Iju, Comprehensive Health Centre Ala Ajagbusi, and Comprehensive Health Centre Oba Ile, located in Akure, Ondo State, Nigeria.

Study design

A descriptive cross-sectional study was conducted at the antenatal wards for pregnant women attending selected primary health-care centers in the study area between February and June 2018. Questionnaires were administered to the sampled pregnant women to collect information about their sociodemographic and clinical data related to UTIs.

Study population

A total of 300 pregnant women attending antenatal care (ANC) at the selected primary health-care centers were randomly selected for the study. The essence of using random sampling techniques in this evaluation is to ensure that each of the antenatal patients who were willing and available at the time of study satisfied the inclusion and exclusion criteria to be recruited in the evaluation for UTIs.

Selection criteria

Inclusion criteria

Pregnant women with or without symptoms of UTI of varied gestational age attending antenatal clinics and with no history of being treated with antibiotic agents for >2 weeks prior to the day of specimen collection were included in this study.

Exclusion criteria

Pregnant women who had taken antibiotics the last 1 week or 2 weeks to the commencement of sampling were excluded from the study.

Sample size and sampling technique

The sample size was computed using the sample size determination table.[16] ANC target population (n = 6000) was obtained from the office of the secretary primary health-care authority.

Ethical considerations

Permission was obtained from Ondo State Ministry of Health, Akure, and Ondo State Primary Health Care Board. Informed consent was requested and granted by the pregnant women under investigation. The concept of the study was explained to them and having understood its dimensions, granted their informed consent.

Sample collection

A total of 300 clean-catch midstream urine samples were collected in sterile screw-capped universal container from consecutive and consenting pregnant women of varied gestational age attending antenatal clinics at the selected primary health-care centers on booking days after proper education on how to collect clean-catch midstream urine samples, labeled, and transported to FUTA Biology Laboratory in an iced pack for processing within 2 h of collection, to ensure maximum recovery of the organisms.

Urinalysis

Dipstick

The urine samples were subjected to a semi-qualitative test using Combi-Uri Screen 10SL Urine Reagent Strips (Accu-Answer by Fas Test Tech Limited 9 St Luke's court, Mountfield Road, London, N33NU, UK) to characterize the presence and levels of chemical entities such as leukocytes, urobilinogen, bilirubin, blood, nitrite, pH, specific gravity (SG), protein, glucose, and ketones. This was done by immersing reagent areas of the strip in a well-mixed urine sample, which is removed immediately to avoid dissolving out of the reagent areas. After 10 s, the color changes are observed and compared with the color chart on the strip container.

Microscopy of the urine samples

A volume of 10 mL each of the urine samples was centrifuged at 1500 rpm for 5 min. The supernatant was decanted and the deposit was re-suspended with the small amount of urine left in the tube by tapping the base of the centrifuge tube. A drop was placed on a clean grease-free glass slide, covered with a cover slip, and examined under microscope using ×10 and ×40 objective lenses for the presence of white blood cells, red blood cells, epithelia cells, casts, crystals, bacteria, yeast cells, and pathogenic protozoans.[17]

Urine culture

A loopful (0.001 mL) of well-mixed uncentrifuged urine was streaked onto the surface of a dried cysteine lactose electrolyte deficient (CLED) medium and nutrient agar. These plates were incubated aerobically at 35°C for 24 h. Colony counts were determined at the end of the incubation period and expressed as colony-forming units (CFU) per milliliter (mL). Each urine sample with over 105 CFU/mL was followed up as significant bacterial growth,[18] and the isolated colonies were sub-cultured on freshly prepared CLED agar incubated at 35°C for 24 h. The purified cultures were stored on nutrient agar slants and identified based on their cultural morphology, Gram staining, as described by Cheesbroug[17] and biochemical reaction according to Ochadaet al.[19]

Statistical analysis

Data were analyzed using Statistical Package for Social Sciences (SPSS) software version 22 Windows-based program (Chicago, IL, USA). Discrete variables were expressed as percentages, and proportions were compared using the Chi-square test. Statistically significant difference was considered at P ≤ 0.05.


  Results Top


[Figure 1] shows the map of the study area. Out of 300 urine samples, 183 (61.0%) were positive for UTI and 117 (39.0%) of the patients were negative. Forty (41.9%), 46 (25.1%), 45 (24.6%), and 52 (28.4%) of the antenatal patients showed significant bacteriuria in Ogbese, Iju, Ala, and Oba Ile health-care centers, respectively [Figure 2].
Figure 1: (a) Map of Nigeria, (b) map of Ondo state, and (c) map of Akure North local government showing the study sites

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Figure 2: Prevalence of urinary tract infection in the study area. χ2 = 29.040, df = 1,P = 0.001

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Dipstick characteristics of the patients

The dipstick urinalysis test results showed that 51 samples (17.0%) tested positive for nitrate, of which 42 (82.4%) showed significant bacteriuria; 21 (7.0) tested positive for leukocytes, of which 17 (80.9%) were infected; traces of protein were recorded in 43 (14.3%), of which 18 (41.9%) were infected; 3 (1.0%) samples tested positive for glucose, out of which 2 (66.7) were infected; and 5 (1.7%) samples tested positive for ketone, with 3 (60.0%) infected. Thirteen (4.3%), 11 (3.7%), and 4 (1.3%) were tested positive for urobilinogen, bilirubin, and blood, respectively. A total of 218 (72.7%) patients tested positive for pH and 260 (86.7%) for SG [Table 1].
Table 1: Dipstick analysis of urine samples in the study areas

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Microscopic analyses of the urine samples

Microscopic examination of the samples showed a high percentage of yeast cells (60 [20.0%]), of which 21 (35.0%) had significant bacteriuria; followed by epithelial cells (53 [17.7%]), of which 23 (43.4%) were infected; calcium oxalate crystals (38 [12.7%]), of which 31 (81.0%) were infected; pus cells (33 [11.0%]), out of which 25 (75.8%) were confirmed infected; and a low percentage of red blood cells (4 [1.3%]) and bacteria (1 [0.3%]).

Protozoans observed were Trichomonas vaginalis (17 [5.7%]) and Schistosoma haematobium ova, Enterobius vermicularis, and Ancylostoma duodenale were 2 (0.7%) each [Table 2].
Table 2: Microscopic examination of urine samples in the study area

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Sociodemographic characteristics of the pregnant women

The distributions of UTI among the infected women according to their sociodemographic characteristics are shown in [Table 3]. The highest infection was recorded in the age group 25–34 years. Relating to marital status, married women constituted the largest proportion of the studied population (269 [89.7%]), of which 101 (55.2%) showed significant bacterial growth.
Table 3: Prevalence of urinary tract infection in relation to the sociodemographic characteristics of the pregnant women in Akure North local government area

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The studied population revealed varying occupation: 208 (69.3%) were businesswomen, out of which 127 (69.4%) showed significant bacteriuria, followed by homemakers (51 [17.0%]), students (24 [8.0%]), and civil servants (17 [5.7%]). Regarding the type of toilet used by the women, 215 (71.5%) used water closet, of which 139 (76.0%) were infected; 58 (19.3%) used other type of toilet such as bush; and 27 (9.0%) used pit toilet.

With regard to the educational level of the participants, 104 (34.7%) had primary education, 90 (30.09%) had secondary education, 67 (22.3%) had it up to higher education, and no formal education took the least 39 (13.09). A total of 147 (49.0%), 124 (41.3%), and 29 (9.7%) women were in the 3rd, 2nd, and 1st trimester of pregnancy, respectively. Going by their obstetric history, out of 209 (69.7%) that were multigravida, 128 (69.9%) were infected and 91 (30.3%) were primigravida. History of UTI, history of previous catheterization, and symptoms of UTI were found in 117 (39.0%), 26 (8.7%), and 35 (11.7%), respectively [Table 3].

Risk factors

There was no statistically significant association between significant bacterial growth and age, marital status, gestational age, gravidity, educational level, occupation, and previous history of catheterization. Type of toilet used, symptoms of UTI, and history of UTI were statistically significantly associated with UTI (P < 0.05) [Table 3].

The pattern of infection in relation to gestational age of the pregnant women as shown revealed that the 3rd trimester had the highest rate of infection; the gravidity showed an even distribution.


  Discussion Top


This study revealed a prevalence of 61% UTI in the pregnant women. Dipstick urinalysis test results showed that nitrite, protein, leukocytes, urobilinogen, bilirubin, blood, and glucose were present. Majority of the urine samples also tested positive for pH and SG. The number of nitrite detected from the urinalysis test could be as a result of Gram-negative bacteria such as E. coli, Klebsiella pneumoniae, and Proteus mirabilis present in the urine, which can reduce nitrate to nitrite. As a result of pathological disorder, protein could be present in urine samples, therefore proteinuria in some of the samples could be a nonspecific biomarker for UTI. The above results agree with Cheesbroug[17] who had previously linked the presence of protein and nitrite in urine to bacterial invasion.

Urine microscopy results showed that 212 urine samples representing 70.8% of the samples tested positive. There was no significant statistical variation (P > 0.05) between these parameters and UTI. However, these results are in agreement with the studies of Stanley and Kayode[3] in Ebonyi state and Battikhi and Battikhi[20] in Amman, Jordan. Protozoans observed were A. duodenale, E. vermicularis, T. vaginalis, and S. haematobium. There was a statistical significance between the protozoans and UTI at P < 0.05, except for T. vaginalis. The findings could be as a result of poor hygienic lifestyle of the pregnant women.

In this study, there was no statistical association between significant bacteriuria and age, marital status, gestational age, gravidity, educational level, occupation, and previous history of catheterization among the pregnant women. This is in agreement with various studies,[21],[22],[23] but disagrees with the study by Ade-Ojo et al.[24] where the gestational age was significantly associated with the prevalence of UTI in pregnant women and a study conducted in a traditional birth home Benin city, Nigeria, where parity and gestational age significantly affected the prevalence of UTI.[25] Nevertheless, UTI prevalence was higher in the age group of 25–34 years; this could be as a result of the age group in question been more sexually active, which may have predisposed them to UTI. These results corroborate the previous reports of various studies[5],[23],[26] where they reported higher prevalence within the age group of 25–34 years. The result of this study is, however, in sharp contrast to a similar study conducted by Okonko et al.[1] who confirmed a high prevalence among the age group of 36–40 years; they contended that the risk of UTIs increases with age, but rather in this study, it increases initially with age and decreases later.

Pregnant women who had recent sexual intercourse of three or more per week were more likely to have UTI than women who had <3 intercourses/week. This may be because sexual activity increases the chances of bacterial contamination of female urethra. Having intercourse may also cause UTIs in women because bacteria can be pushed into the urethra. The anatomical relationship of the female urethra to the vagina makes it liable to trauma during sexual intercourse as well as bacteria can also be massaged up from the urethra into the bladder during pregnancy and childbirth.[1] The prevalence of UTI in this study increases with gestational age and gravidity, which is similar to the report of Emiru et al.[27]

Type of toilet used in this study was statistically significant (P = 0.02). The frequency of UTI (76%) was higher among pregnant women who used water closet. This may be as a result of improper cleaning after using the toilet. This is curbed in most developed countries with a handheld running tap attached to the toilet for cleaning purpose after using the toilet. In addition, most of the studied women using water closet end up cleaning with paper/tissue paper after toilet; this could also contribute to the high prevalence as tissue paper could not ensure proper cleaning and as a result of this, the undergarment can interact with the leftover, sweat, and friction between the laps while walking, which could transfer organisms to the vaginal region.[28]

Symptoms and previous history of UTI were statistically significant at P = 0.005 and P = 0.001, respectively. The result compared favorably with those of previous studies conducted by some authors.[23],[27],[29] They recorded a significant association between previous history of UTI and prevalence. This might be due to ineffective treatment or presence of resistance strains from those who had a previous history of UTI.


  Conclusion Top


The present study shows that the overall prevalence of UTI among pregnant women in the study area was high. It was observed that pregnant women are at high risk of UTI; therefore, frequent and consistent evaluation of the prevalence and associated risk factors in the study area and screening of pregnant women during antenatal clinics should be considered very important to avoid complications. Health education with regular antenatal and personal hygiene is recommended as a precautionary measure to UTI.

Acknowledgment

The authors thank the nurses and ward maids of the various primary health-care centers for their contribution during data collection. The authors are grateful to the ethical review boards of the Federal University of Technology, Akure, and Ondo State Ministry of Health for giving ethical clearance. The authors appreciate the patients for giving their consent to participate in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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