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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].
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