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ABSTRACT 

Urinary tract infection (UTI) represents a serious health problem in pregnant women. The severity of urinary tract infection depends both on the virulence of the bacteria and the susceptibility of the host. The aim of this study was to determine the prevalence of urinary tract infection and demographic differentials among pregnant women in University of Nigeria Teaching Hospital Enugu. The objectives were to determine the proportion of women who have UTI, identify the common causative organism and to determine difference in UTI occurrence among pregnant women based on demographic variables. Two hundred and twenty five pregnant women that attended antenatal clinic within the period of study were investigated. Personal data were collected using a structured questionnaire. Early morning midstream clean urine samples were collected from all participants who were willing to participate for diagnosis of UTI. Urine samples were cultured using standard loop technique on blood agar, cystein lactose electrolyte deficient medium agar and macconkey agar. The result revealed that a total of 117 (52%) out of the 225 women had UTI. The organism most implicated was E. Coli (30.7%). Higher parity and older maternal age were significantly associated with UTI among pregnant women (P < .05). Gestational age, maternal level of education and maternal economic status were not significantly associated with the occurrence of UTI among the pregnant women (P > .05). From the findings it was concluded that UTI occur in pregnancy, affecting older women and those with more number of children. Screening for UTI is important in every pregnancy to reduce the incidence of low birth weight and prematurity and to also improve maternal and child health.

 CHAPTER ONE

INTRODUCTION

Background to the Study

Urinary tract infections (UTIs) during pregnancy are among the most common health problems afflicting many women in their reproductive years (Wamalma, Onolo, & Makokha, 2013). Pregnant women are at increased risk for UTIs beginning at the 6^th week of gestation and peaking during 22 to 24 weeks of gestation due to a number of anatomical and physiological factors (Wamalma, Onolo, & Makokha, 2013). Screening for and treatment of bacteriuria in pregnancy has become a standard obstetric care in many countries. For instance, American College of Obstetricians and Gynecologists, National Institute for Health and Clinical Experience, and American Academy of Family Physicians strongly recommend screening for bacteriuria in all pregnant women at 12 to 16 weeks gestation with urine culture or at the first prenatal visit (Ashshi, Faidah, Saati, Abou, Al-Ghamdi, & Mohamed 2012).

Urinary tract infection is a bacterial infection occurring in the urinary system. The urinary system consists of the kidneys, ureters, bladder and the urethra.  The severity of UTI depends both on the virulence of the bacteria and the susceptibility of the host (Ade-Ojo,Oluleye,& Adegun, 2013). Although pregnancy does not increase the rate of UTI, it increases the risk of progressing to a full blown kidney infection, which can cause early labour and other pregnancy complications (Wamalma, Onolo, & Makokha, 2013). UTI portends adverse outcome if not treated. Studies have shown that 20-40 percent of UTI progresses to acute pyelonephritis if untreated whereas with treatment this risk reduces to 1-2 percent (Schnarr, 2008).  Maternal complications include chronic pyelonephritis, anemia, and septicaemia. Fetal complications include intrauterine growth restrictions and prematurity (Ade-Ojo, Oluleye, & Adegun, 2013).

There are factors that predispose to bacteriuria in pregnancy and they include the reduced ability of the kidneys to concentrate urine, leading to differences in urine ph and osmolality of urine in pregnancy, stasis of urine due to smooth muscle relaxation, effect of increased progesterone, pressure effect of the gravid uterus on the bladder and ureters impeding the free flow of urine (Ade-Ojo, Oluleye, & Adegun, 2013). UTI can occur in both males and females at any age. Bacteriuria increases with age, and women are affected more frequently than men. This is because of their short urethra which offers little resistance to the movement of uropathogenic bacteria, also structural and functional problems which occur with aging may prevent complete emptying of the bladder which leads to UTI.  Also studies have shown that the body’s resistance to infection and ability to recover from infection diminishes with age (Smeltzer, Bare, Hinkle, & Cheever, 2008). In other words, older women may be more susceptible to infection than younger women due to ageing.

Sexual intercourse or massage of the urethra during childbirth forces bacteria up into the bladder. This accounts for the increased incidence of UTI in sexually active women (Smeltzer, et al., 2008). The study by Wamalma, Onolo and Makokha (2013) showed that 72.4 percent of significant bacteriuria occurred among 25-34-year age group which is usually the active stage of sexual activities for most women. It has been noted that the probability of UTIs increases with gestational age (Okonko, Ijandipe, Ilusanya, Donbraye, Ejembi & Udeze 2009). This may, for instance, be explained by increased pressure of the pregnant uterus on the bladder leading to stasis of urine. Pregnancy and childbirth compel women to undergo processes that may expose them to UTI. For instance, higher parity may expose the woman to higher likelihood of contracting UTIs. Accessing standard healthcare is still an issue for a lot of women in developing countries due to limited knowledge and availability of qualified personnel and infrastructure. The available qualified personnel and infrastructure are sometimes beyond the affordability of majority of the women due to their low level of income and distance to orthodox health care facilities. Although government subsidises the healthcare services in such countries, it is not always available to some of the women. The consequence is that some of them engage in self-diagnosis and self-medication, utilisation of unapproved and ineffective traditional health practices, or patronise quack medical practitioners. Level of knowledge may be related to women’s knowledge of available standard medical facilities and personnel and the need to utilize them.

Understanding the factors that increase UTI in pregnancy is fundamental to reducing and improving maternal health in pregnancy. Based on this, it is important to investigate whether some demographic factors such as maternal age, parity, gestational age, socioeconomic status, or level of education are associated with UTI among pregnant women.   

Statement of the Problem

UTI in pregnancy leads to poor pregnancy outcome. According to Haider, Zehr, Munir, and Haider (2010), the prevalence of UTIs in pregnancy globally ranges from 13%-33% with asymptomatic bacteriuria occurring in 2-10% during pregnancies while symptomatic has been found to account for 1-18% during pregnancies. UTI in pregnancy is a serious problem with complications such as prematurity and low birth weight. Prematurity and low birth weights are associated with poor infant survival.  Currently in Enugu State, in line with the sustainable development goals (SDGs no 3) which is to ensure healthy lives and promote well-being for all ages, urinalysis is one of the basic laboratory tests done in the first antenatal visit. This is to detect and treat UTI early in pregnancy or reduce it to the barest minimum and to reduce the chances of prematurity and low birth weight which are linked with infant mortality. In spite of this effort the incidence of UTI is still common among pregnant women who attend ante-natal clinic at University of Nigeria Teaching Hospital (UNTH) ituku ozalla. From records available in University of Nigeria Teaching Hospital, Enugu, between June and September 2013, out of 300 pregnant women who were treated of different ailments, 25 were diagnosed of UTI, representing 8 percent of the population that had problem in pregnancy (UNTH records). The questions being raised are, Is the problem due to maternal age, gestational age, parity, economic status and level of education or due to combination of these factors? There is need to identify the demographic factors which increase the occurrence of UTI in pregnancy.   

Purpose of the Study

The purpose of this study was to determine the prevalence of UTI and demographic differentials (parity, gestational age, maternal age, economic status and level of education) among pregnant women in UNTH Enugu.

Objectives of the Study

Objectives of the study are to:

1. determine the proportion of women who has UTI   among pregnant women attending antenatal care in UNTH
2. identify the common causal organisms of UTI  among pregnant women attending antenatal care in UNTH
3. determine the differences in UTI occurrence among pregnant women attending antenatal care in UNTH based on parity
4. ascertain the differences in UTI occurrence among pregnant women attending antenatal care in UNTH based on gestational age
5. assess the differences in UTI occurrence among pregnant women attending antenatal care in UNTH based on maternal age.
6. examine the differences in UTI occurrence among pregnant women attending antenatal care in UNTH based on educational level.
7. determine the differences in UTI occurrence among pregnant women attending antenatal care in UNTH based on economic level.

Research Hypotheses

There would be no significant difference UTI among pregnant women attending antenatal care in UNTH based on their demographic differentials (parity, gestational age, maternal age, maternal level of education and maternal economic level). 

Significance of the Study

The pregnant women will benefit from the findings of this study. If the demographics are associated with UTI in pregnant women, the finding will reveal the particular demographics of pregnant women that influence UTI. The information will help nurses and other health care providers to know the group of pregnant women that are more vulnerable. Also the information from the findings will help the hospital policy makers or stakeholders to know the factors affecting UTI and help to improve on their strategies towards reducing the incidence of UTI.  Such practices may reduce UTI problems in pregnancy; reduce the risk of premature delivery; and improve women’s health. On the other hand if UTI among pregnant women is not associated demographic differences, this study will make room for other studies to be conducted to improve maternal and child health. 

Scope of the Study

This study is delimited to University of Nigeria Teaching Hospital Ituku-Ozalla

Enugu. The study is also delimited to the investigation of demographic differences (maternal age, parity, gestational age, economic status and educational level) in UTI occurrence among pregnant women attending antenatal in UNTH. 

Operational Definition of Terms

1. Urinary Tract Infection refer to the presence of bacteria in the urine. Urine samples of pregnant women will be collected and cultured within 24hours using standard loop technique on blood agar,cystein lactose electrolyte deficient (CLED) medium agar and macconkey agar in laboratory. UTI will be established if the urine sample counts greater or equals to 100,000 of bacteria per ml of urine.
2. Demographic differentials used in this study are parity, gestational age, maternal age and economic status that may be associated with the occurrence of urinary tract infection.
3. Economic level of the women refer to the level of financial status of the women attending antenatal in UNTH

4     Pregnant women refer to women between 20-49years who have one to six children irrespective of gestational age and marital status.