Prevalence of Urinary Tract Infection and Its Associated Factors among Pregnant Women in Ethiopia: A Systematic Review and Meta-Analysis

BioMed Research International, Volume 2021, Year 2021

Interpretation

Objective. Urinary tract infection (UTI) is the most common bacterial infections during pregnancy. It is associated with different maternal and neonatal adverse outcomes such as low birth weight, preterm birth, still birth, preeclampsia, maternal anemia, sepsis, and amnionitis, even when the infection is asymptomatic. However, in Ethiopia, it is represented with fragmented and inconclusive pocket studies. Therefore, this systematic review and meta-analysis is aimed at estimating the pooled prevalence of UTI and its associated factors among pregnant women in Ethiopia. Methods. PubMed/Medline, Embase, Cochrane Library, Google Scholar, and local sources were used to access eligible studies. Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument was applied for critical appraisal. Heterogeneity and publication bias were evaluated using I2 statistic, funnel plot asymmetry, and Egger’s tests. Random effect model was employed to estimate the pooled burden of UTI and its associated factors among pregnant women with its corresponding odds ratio (OR) and 95% confidence interval (CI). Result. From all systematically searched articles, 14 studies were eligible for this analysis. The overall pooled prevalence of UTI among pregnant women in Ethiopia was 15.37% (95% CI: 12.54, 18.19). Family monthly income (OR=3.8 and 95% CI: 1.29, 11.23), parity (OR=1.59 and 95% CI: 1.01, 2.50), history of catheterization (OR=2.76 and 95% CI: 1.31, 5.84), and history of UTI (OR=3.12 and 95% CI: 1.74, 5.60) were factors significantly associated with UTI among pregnant women in Ethiopia. Conclusion. The overall pooled estimate of UTI among pregnant women in Ethiopia was higher compared with CDC estimation which was 8%. Family monthly income<1000ETB, multipara, previous history of catheterization, and history of UTI were factors increased burden of UTI during pregnancy. So, strategies targeting in economic reforms, universal access of family planning, and standardized prenatal care service should be addressed to alleviate this high prevalence of UTI during pregnancy. From Prospero, burden of UTI and its associated factors among pregnant women in Ethiopia: systematic review and meta-analysis was searched to avoid duplication. To the best of our knowledge, this is the first systematic review meta-analysis done in Ethiopia in this title. PubMed, Medline, Embase, Cochrane Library, Google Scholar, and local sources including academic and governmental institution online library were used to access included articles. In addition, the cross-references (lists of already identified articles references) were applied to retrieve studies. The key terms used for systematically searching relevant literatures were UTI, asymptomatic or symptomatic, bacteriuria, bacteria profile, prenatal, pregnancy, antenatal, associated factors, determinants, predictors, risk factors, causes, and Ethiopia. All studies on electronic databases and local sources were searched till March/2021. Then, identified articles were exported into endnote citation manager software version X7 for Windows to exclude duplicate records. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA) checklist guidelines [34] were used to develop this systematic review and meta-analysis. Study scope: all studies conducted in all regional states and administrative cities of Ethiopia on burden of UTI and its associated factors during pregnancy were included under this systematic review and meta-analysis. No restriction was applied to language, study design, study setting, and publication. Population: all reproductive aged women (15-49 years) who were pregnant at least once were considered for this review. Exposure: all studies explored burden of UTI and its associated factors among pregnant women in Ethiopia were included. Outcome variable: studies which diagnosed UTI during pregnancy when their urine yielding positive cultures (≥105 CFU/ml) were included for this review. After all identified studies title and abstract screened for eligibility, studies unrelated to our review title were excluded. Then, full texts of those articles related to our title and eligible were critically examined. However, those papers which did not fully access at the time of our search process were excluded after contact was attempted with the principal investigator through email at least two times. Furthermore, after reviewing full texts of all eligible studies, studies which did not report our outcome of interest and studies with poor quality as per settled criteria of reviewing the articles were excluded from the final analysis. Data extraction was undertaken using standardized data extraction Excel spreadsheet format prepared according to 2014 Joanna Briggs Institute Reviewers' Manual [35]. This standardized data extraction format includes the following: author name, study of region, publication year, study design, sampling technique, study setting, sample size, mean age of respondent, standard used to diagnosed UTI, response rate, and prevalence of UTI among pregnant women. Factors associated with UTI during pregnancy were also systematically extracted using cross tabulation between UTI and those potential-associated factors (including sociodemographic factors like maternal age (≥25 yrs vs. <25 yrs), residence (rural vs. urban), marital status (married vs. single), maternal educational status (illiterate vs. formal education), monthly family income (<1000ETB vs. ≥1000ETB in which 1000ETB is equivalent with 23.8$ and we have used the cut point 1000ETB because the exist data were not classified based similarly and not based on national income level classification), and maternal occupation (housewife vs. employed)) and medical and obstetric related factors like anemia (yes vs. no), HIV status (positive vs. negative), history of UTI (yes vs. no), history of catheterization (yes vs. no), parity (multipara vs. primipara and nulliparous), and gestational age (second and third trimester vs. first trimester). Disagreements between the authors were resolved by face to face discussion and consensus. Before data extraction was handled, critical appraisal of included and eligible studies was employed using Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) [35]. In the appraisal tool, randomness of subject selection, clear definition of inclusion criteria, identification and addressing for confounding factors, clear objective, and reliable measurement of outcome variable and use of appropriate statistical analysis method were included. Two independent reviewers evaluated each included individual studies critically. Disagreements between the reviewers were resolved via discussion and consensus. If not, the third reviewer was involved. Finally, those articles scored five and above were considered in this review. We assessed and evaluated the methodological quality and risk of bias in the studies that were selected using the 10-item rating scale developed by Hoy et al. for prevalence studies [36]. Sampling, data collection, reliability and validity of study tools, case definition, and prevalence periods were included in the tool. The rating scale was categorized as having low risk of bias (“yes” answers to domain questions) or high risk of bias (“no” answers to domain questions) for each articles. Each study was assigned a score of 1 (yes) or 0 (no) for each domain, and these scores were summed to provide an overall study quality score. Scores of 8-10 were considered as having a “low risk of bias,” 6–7 a “moderate risk,” and 0–5 a “high risk.” For the final risk of bias classification, disagreements between the reviewers were resolved via consensus. The primary outcome of this systematic review and meta-analysis was estimating the pooled burden of UTI among pregnant women in Ethiopia. UTI during pregnancy was diagnosed when their midstream urine sample yields positive cultures (≥105 CFU/ml) in either symptomatic or asymptomatic pregnant women. In addition, this review is also aimed at identifying factors associated with the pooled burden of UTI during pregnancy. Generally, sociodemographic factors like maternal age, residence, marital status, maternal educational status, monthly family income, and maternal occupation and medical and obstetric related factors like anemia, HIV status, history of UTI, history of catheterization, parity, and gestational age were identified factors to be associated with burden of UTI. Those data extracted using the prepared Excel spreadsheet format were imported to Stata version 14 for further analysis. The existence of heterogeneity was assessed using the Cochran's Q statistic while the inverse variance (I2) was used to quantify it. A value at 25%, 50%, and 75% was considered as low, moderate, and high heterogeneity across studies, respectively [37]. In addition, Egger's regression test and asymmetry funnel plot were applied to assess publication bias [38]. Furthermore, p value less than 0.05 was used to declare the presence of heterogeneity across studies and publication bias. Random effect model was computed to estimate the pooled burden of UTI and its associated factors during pregnancy using forest plot diagram with their corresponding 95% CI and OR. Moreover, subgroup analysis and metaregression were conducted to explore potential sources of heterogeneity across studies using different characteristics of the studies. Generally, the methodology part of our research may be overlapped with our previous work which was unpublished (leave for further updating and overall changing) [39].

AI Digest

Study Justification:

– Urinary tract infection (UTI) is a common bacterial infection during pregnancy and can lead to adverse outcomes for both the mother and the baby.
– In Ethiopia, there is a lack of comprehensive and conclusive studies on the prevalence of UTI among pregnant women.
– This systematic review and meta-analysis aims to fill this gap by estimating the pooled prevalence of UTI and identifying its associated factors among pregnant women in Ethiopia.

Study Highlights:

– The overall pooled prevalence of UTI among pregnant women in Ethiopia was found to be 15.37%.
– Factors significantly associated with UTI among pregnant women in Ethiopia include family monthly income, parity, history of catheterization, and history of UTI.
– The prevalence of UTI among pregnant women in Ethiopia is higher than the estimation by the Centers for Disease Control and Prevention (CDC), which was 8%.

Study Recommendations:

– Strategies targeting economic reforms should be implemented to address the higher prevalence of UTI among pregnant women with low family monthly income.
– Universal access to family planning services should be promoted to reduce the burden of UTI during pregnancy.
– Standardized prenatal care services should be implemented to effectively prevent and manage UTI among pregnant women in Ethiopia.

Key Role Players:

– Ministry of Health: Responsible for implementing and overseeing the strategies and interventions to address UTI among pregnant women.
– Healthcare Providers: Including doctors, nurses, and midwives who provide prenatal care and education to pregnant women.
– Community Health Workers: Involved in community outreach and education programs to raise awareness about UTI prevention and management during pregnancy.
– Non-Governmental Organizations (NGOs): Collaborating with the government to implement programs and initiatives targeting UTI prevention and management among pregnant women.

Cost Items for Planning Recommendations:

– Economic Reforms: Budget allocation for programs aimed at improving the economic status of pregnant women with low family monthly income.
– Family Planning Services: Budget for the provision of accessible and affordable family planning services to reduce the burden of UTI during pregnancy.
– Prenatal Care Services: Budget for the establishment and maintenance of standardized prenatal care services to effectively prevent and manage UTI among pregnant women.
– Training and Education: Budget for training healthcare providers and community health workers on UTI prevention and management during pregnancy.
– Awareness Campaigns: Budget for community outreach programs and awareness campaigns to educate pregnant women and their families about UTI prevention and the importance of seeking timely care.

Strength of Evidence

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is rated 8 because it provides a clear objective, describes the methods used for data collection and analysis, and presents the results of the systematic review and meta-analysis. However, it does not mention the specific inclusion and exclusion criteria used for selecting studies, and it does not provide information on the quality assessment of the included studies. To improve the evidence, the abstract could include a brief description of the inclusion and exclusion criteria, as well as a summary of the quality assessment results. This would provide more transparency and help readers assess the reliability of the findings.

Abstract

From Prospero, burden of UTI and its associated factors among pregnant women in Ethiopia: systematic review and meta-analysis was searched to avoid duplication. To the best of our knowledge, this is the first systematic review meta-analysis done in Ethiopia in this title. PubMed, Medline, Embase, Cochrane Library, Google Scholar, and local sources including academic and governmental institution online library were used to access included articles. In addition, the cross-references (lists of already identified articles references) were applied to retrieve studies. The key terms used for systematically searching relevant literatures were UTI, asymptomatic or symptomatic, bacteriuria, bacteria profile, prenatal, pregnancy, antenatal, associated factors, determinants, predictors, risk factors, causes, and Ethiopia. All studies on electronic databases and local sources were searched till March/2021. Then, identified articles were exported into endnote citation manager software version X7 for Windows to exclude duplicate records. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA) checklist guidelines [34] were used to develop this systematic review and meta-analysis. Study scope: all studies conducted in all regional states and administrative cities of Ethiopia on burden of UTI and its associated factors during pregnancy were included under this systematic review and meta-analysis. No restriction was applied to language, study design, study setting, and publication. Population: all reproductive aged women (15-49 years) who were pregnant at least once were considered for this review. Exposure: all studies explored burden of UTI and its associated factors among pregnant women in Ethiopia were included. Outcome variable: studies which diagnosed UTI during pregnancy when their urine yielding positive cultures (≥105 CFU/ml) were included for this review. After all identified studies title and abstract screened for eligibility, studies unrelated to our review title were excluded. Then, full texts of those articles related to our title and eligible were critically examined. However, those papers which did not fully access at the time of our search process were excluded after contact was attempted with the principal investigator through email at least two times. Furthermore, after reviewing full texts of all eligible studies, studies which did not report our outcome of interest and studies with poor quality as per settled criteria of reviewing the articles were excluded from the final analysis. Data extraction was undertaken using standardized data extraction Excel spreadsheet format prepared according to 2014 Joanna Briggs Institute Reviewers' Manual [35]. This standardized data extraction format includes the following: author name, study of region, publication year, study design, sampling technique, study setting, sample size, mean age of respondent, standard used to diagnosed UTI, response rate, and prevalence of UTI among pregnant women. Factors associated with UTI during pregnancy were also systematically extracted using cross tabulation between UTI and those potential-associated factors (including sociodemographic factors like maternal age (≥25 yrs vs. <25 yrs), residence (rural vs. urban), marital status (married vs. single), maternal educational status (illiterate vs. formal education), monthly family income (<1000ETB vs. ≥1000ETB in which 1000ETB is equivalent with 23.8$ and we have used the cut point 1000ETB because the exist data were not classified based similarly and not based on national income level classification), and maternal occupation (housewife vs. employed)) and medical and obstetric related factors like anemia (yes vs. no), HIV status (positive vs. negative), history of UTI (yes vs. no), history of catheterization (yes vs. no), parity (multipara vs. primipara and nulliparous), and gestational age (second and third trimester vs. first trimester). Disagreements between the authors were resolved by face to face discussion and consensus. Before data extraction was handled, critical appraisal of included and eligible studies was employed using Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) [35]. In the appraisal tool, randomness of subject selection, clear definition of inclusion criteria, identification and addressing for confounding factors, clear objective, and reliable measurement of outcome variable and use of appropriate statistical analysis method were included. Two independent reviewers evaluated each included individual studies critically. Disagreements between the reviewers were resolved via discussion and consensus. If not, the third reviewer was involved. Finally, those articles scored five and above were considered in this review. We assessed and evaluated the methodological quality and risk of bias in the studies that were selected using the 10-item rating scale developed by Hoy et al. for prevalence studies [36]. Sampling, data collection, reliability and validity of study tools, case definition, and prevalence periods were included in the tool. The rating scale was categorized as having low risk of bias (“yes” answers to domain questions) or high risk of bias (“no” answers to domain questions) for each articles. Each study was assigned a score of 1 (yes) or 0 (no) for each domain, and these scores were summed to provide an overall study quality score. Scores of 8-10 were considered as having a “low risk of bias,” 6–7 a “moderate risk,” and 0–5 a “high risk.” For the final risk of bias classification, disagreements between the reviewers were resolved via consensus. The primary outcome of this systematic review and meta-analysis was estimating the pooled burden of UTI among pregnant women in Ethiopia. UTI during pregnancy was diagnosed when their midstream urine sample yields positive cultures (≥105 CFU/ml) in either symptomatic or asymptomatic pregnant women. In addition, this review is also aimed at identifying factors associated with the pooled burden of UTI during pregnancy. Generally, sociodemographic factors like maternal age, residence, marital status, maternal educational status, monthly family income, and maternal occupation and medical and obstetric related factors like anemia, HIV status, history of UTI, history of catheterization, parity, and gestational age were identified factors to be associated with burden of UTI. Those data extracted using the prepared Excel spreadsheet format were imported to Stata version 14 for further analysis. The existence of heterogeneity was assessed using the Cochran's Q statistic while the inverse variance (I2) was used to quantify it. A value at 25%, 50%, and 75% was considered as low, moderate, and high heterogeneity across studies, respectively [37]. In addition, Egger's regression test and asymmetry funnel plot were applied to assess publication bias [38]. Furthermore, p value less than 0.05 was used to declare the presence of heterogeneity across studies and publication bias. Random effect model was computed to estimate the pooled burden of UTI and its associated factors during pregnancy using forest plot diagram with their corresponding 95% CI and OR. Moreover, subgroup analysis and metaregression were conducted to explore potential sources of heterogeneity across studies using different characteristics of the studies. Generally, the methodology part of our research may be overlapped with our previous work which was unpublished (leave for further updating and overall changing) [39].

Materials

N/A

Innovations

Based on the provided information, it seems that the focus is on conducting a systematic review and meta-analysis to estimate the prevalence of urinary tract infections (UTIs) among pregnant women in Ethiopia and identify associated factors. The study aims to improve access to maternal health by addressing the high prevalence of UTIs during pregnancy. Some potential recommendations for innovations to improve access to maternal health based on this study could include:

1. Strengthening prenatal care services: Implementing standardized prenatal care protocols that include routine screening and management of UTIs during pregnancy can help identify and treat infections early, reducing the associated adverse outcomes.

2. Health education and awareness: Develop educational programs targeting pregnant women and their families to raise awareness about the risks and consequences of UTIs during pregnancy. This can include information on preventive measures, such as proper hygiene practices and the importance of seeking timely medical care.

3. Integration of UTI screening into antenatal care: Incorporate routine UTI screening as part of antenatal care visits to ensure early detection and appropriate management of infections. This can be done by providing urine sample collection facilities at healthcare facilities and training healthcare providers on UTI screening protocols.

4. Strengthening laboratory capacity: Improve laboratory facilities and resources to enable accurate and timely diagnosis of UTIs during pregnancy. This can involve providing necessary equipment, training laboratory staff, and ensuring the availability of appropriate diagnostic tests.

5. Addressing socioeconomic factors: Develop strategies to address socioeconomic factors associated with UTIs during pregnancy, such as low family income. This can include initiatives to improve economic opportunities for women, increase access to family planning services, and provide financial support for prenatal care.

6. Collaboration and coordination: Foster collaboration between healthcare providers, researchers, policymakers, and community organizations to develop comprehensive strategies for addressing UTIs during pregnancy. This can involve sharing knowledge and best practices, advocating for policy changes, and ensuring the implementation of evidence-based interventions.

It is important to note that these recommendations are based on the information provided and may need to be further tailored and adapted to the specific context and needs of Ethiopia’s healthcare system.

AI Innovations Description

Based on the provided description, the recommendation to improve access to maternal health and address the high prevalence of urinary tract infections (UTIs) among pregnant women in Ethiopia is as follows:

1. Strengthen Economic Reforms: Implement strategies that target economic reforms to improve the financial situation of pregnant women and their families. This can include initiatives such as income-generating programs, job opportunities, and social support systems to ensure that families have the financial means to access quality maternal healthcare.

2. Universal Access to Family Planning: Promote and ensure universal access to family planning services. This can help prevent unintended pregnancies, which are associated with a higher risk of UTIs during pregnancy. Family planning services should include education, counseling, and a wide range of contraceptive options to meet the diverse needs of women.

3. Standardized Prenatal Care Services: Improve the quality and accessibility of prenatal care services across Ethiopia. This can be achieved by implementing standardized guidelines and protocols for prenatal care, training healthcare providers on best practices, and ensuring that essential resources and equipment are available in healthcare facilities.

4. Health Education and Awareness: Conduct health education campaigns to raise awareness about the risk factors and prevention of UTIs during pregnancy. This can include educating pregnant women and their families about proper hygiene practices, the importance of regular prenatal check-ups, and the early detection and treatment of UTIs.

By implementing these recommendations, it is expected that access to maternal health will be improved, leading to a reduction in the prevalence of UTIs among pregnant women in Ethiopia and better overall maternal and neonatal outcomes.

AI Innovations Methodology

Based on the provided description, here are some potential recommendations to improve access to maternal health:

1. Strengthening prenatal care services: Enhance the availability and quality of prenatal care services, including regular check-ups, screenings, and education on maternal health issues such as urinary tract infections (UTIs). This can be achieved by training healthcare providers, improving infrastructure, and ensuring the availability of necessary medical supplies.

2. Increasing awareness and education: Implement comprehensive awareness campaigns targeting pregnant women and their families to increase knowledge about the importance of maternal health and the prevention and management of UTIs. This can be done through community outreach programs, educational materials, and media campaigns.

3. Improving access to clean water and sanitation: Enhance access to clean water and sanitation facilities, particularly in rural areas, to reduce the risk of UTIs and other infections during pregnancy. This may involve infrastructure development, such as building water supply systems and improving sanitation facilities in healthcare facilities and communities.

4. Strengthening health systems: Invest in strengthening the overall health system, including improving healthcare infrastructure, training healthcare workers, and ensuring the availability of essential medicines and equipment for the prevention, diagnosis, and treatment of UTIs and other maternal health conditions.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify specific indicators that can measure the impact of the recommendations, such as the percentage of pregnant women receiving prenatal care, the prevalence of UTIs among pregnant women, and the availability of clean water and sanitation facilities in healthcare facilities.

2. Collect baseline data: Gather data on the current status of maternal health and access to care, including the prevalence of UTIs, the percentage of pregnant women receiving prenatal care, and the availability of clean water and sanitation facilities. This can be done through surveys, interviews, and data from healthcare facilities and government reports.

3. Develop a simulation model: Create a simulation model that incorporates the identified indicators and their interrelationships. This model should consider factors such as population size, geographical distribution, healthcare infrastructure, and resource availability.

4. Define intervention scenarios: Develop different scenarios that represent the implementation of the recommendations, such as increasing the number of prenatal care visits, improving water and sanitation facilities, and enhancing healthcare provider training. Each scenario should include specific targets and timelines.

5. Simulate the impact: Use the simulation model to project the potential impact of each intervention scenario on the identified indicators. This can be done by adjusting the relevant parameters in the model and running simulations to estimate the changes in the indicators over time.

6. Analyze and interpret the results: Analyze the simulation results to assess the potential impact of the recommendations on improving access to maternal health. Compare the outcomes of different scenarios and identify the most effective interventions based on the desired outcomes.

7. Validate the results: Validate the simulation results by comparing them with real-world data and feedback from stakeholders, such as healthcare providers and policymakers. This can help ensure the accuracy and reliability of the simulation model.

8. Communicate the findings: Present the findings of the simulation study in a clear and concise manner, highlighting the potential benefits of implementing the recommended interventions. This can be done through reports, presentations, and policy briefs to inform decision-makers and stakeholders about the potential impact on improving access to maternal health.

It is important to note that the methodology described above is a general framework and can be adapted and customized based on the specific context and available data.

Author

Dima Health

Statistics:

Citations: 1

Identifiers:

DOI: 10.1155/2021/6551526

ISSN: 23146133

Research Areas:

Genetics and Genomics, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Technology and Innovations

Study Countries:

Ethiopia

Study Design:

Case-Control Study, Cross Sectional Study, Grounded Theory

Study Approach:

Mixed-methods, Quantitative, Systematic Review

Participants Gender:

Female