Prevalence, Predictors and Effect of Vitamin D Probiotics Fortification on Asymptomatic Urinary Tract Infections Among Pregnant Women: A Prospective Cohort Study

doi:10.21203/rs.3.rs-4612438/v1

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Research Article

Prevalence, Predictors and Effect of Vitamin D Probiotics Fortification on Asymptomatic Urinary Tract Infections Among Pregnant Women: A Prospective Cohort Study

https://doi.org/10.21203/rs.3.rs-4612438/v1

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Background

Maternal urinary tract infections (UTIs) remains the commonest non-intestinal infection globally, and it is a major public health concern. Moreover, Vitamin D is a known immunomodulator, and its deficiency is common in pregnant women. Few evidence shows vitamin D deficiency may expose the urinary tract to infections. For the first time, this study investigated the prevalence, associated factors and effect of Vitamin D probiotics fortification on asymptomatic UTIs among pregnant women in Ghana.

Methods

This prospective cohort study included 126 pregnant women aged 18 years and above without symptoms of UTI attending antenatal care at the Ejisu Government Hospital and Juaben Government Hospital in Ejisu-Juaben Municipality in the Ashanti Region, Ghana. Pregnant women were further divided into Vitamin D probiotics fortified group (63) and non-fortified group (63) and follow-up for 6 months. Sociodemographic and clinical data were collected. Venous blood samples were also collected at baseline and end line for laboratory analyses. Quantification of serum 25(OH)D levels was done using ELISA (Thermo scientific). Statistical analyses were done in SPSS version 26.0 and GraphPad version 8.0 at p < 0.05 and 95% confidence interval.

Results

This study found 23.6% prevalence of UTI among pregnant women with most isolated bacteria being Escherichia coli (69.0%) and staphylococcus spp. (17.2%). In a logistics regression prediction model, inadequate knowledge on UTI (cOR: 2.85, 95% CI: (1.00-8.14); p = 0.049) was significantly associated with 3-odds increased likelihood of UTI, and poor attitude towards UTI (aOR: 3.00, 95% CI: (1.22–7.37); p = 0.017) was independent predictor of increased chances of UTI among pregnant women. At end line of treatment, the prevalence of UTI among Vitamin D fortified group reduced from 21.0–3.2% and among non-fortified group reduced from 26.2% 16.4%, indicating a drastic effects of Vitamin D fortification in reducing UTI among pregnant women.

Conclusion

The prevalence of UTI remains high among pregnant women. Inadequate knowledge on UTI and poor attitude towards UTI contributes significantly to increasing chances of UTI among pregnant women. However, public health strategies incorporating Vitamin D supplementation could reduce UTI incidences and related adverse maternal and neonatal outcomes.

Urinary tract infections (UTIs)

Vitamin D

Escherichia coli

Urinary Tract Infections (UTIs) remains the commonest non-intestinal infection globally, and it is a major public health concern. The prevalence of UTI globally ranges from 3 to 50% worldwide (1, 2), with developing countries recording the highest prevalence of UTI (1). It is estimated that the ratio of male to female infection is 1:8 (3). Globally, one in every three adult female have experience symptomatic UTI and one half also experiences recurring UTI due to previous UTI infection (2, 4). Increased females susceptible to UTI compared to male has been attributed to factors including, women having shorter urethra and is nearer to the anus than men which make infection more easier (5). Also, the UT (urinary tract) of women is more likely to get infected during sexual activity, can easily be contaminated with flora from faeces, hormonal changes and pregnancy (6). Moreover, pregnant women are 4 times more at risk of UTI compared to non-pregnant women, posing great threat to both the mother and the child (7, 8).

The risk of pregnant women contracting UTI mostly begins from the 6th week and peak mostly at 22nd to 24th week of conception (9, 10). This is because from the 22nd to the 24th week, there is increased bladder volume, high dilation of the urethra and the urethra tone decreases, leading to high urinary stasis and vesicoureteral reflux (11). Also, glycosuria occurs in about 70% of women making pregnant women more susceptible to UTI (12). The most common agent of UTI is E. coli and is responsible for 68 to 77% of all UTI infections (13). UTIs can either be symptomatic or asymptomatic and are associated with serious obstetric complications, poor maternal and neonatal outcomes including as low birth weight, preterm birth, stillbirth, maternal anaemia, preeclampsia, and miscarriage (14, 15). Untreated UTI can lead to maternal and fetal complications like intra-amniotic infection, intrauterine growth restriction, rapture of the membrane prematurely, septicemia and prenatal deaths (13). Early detection and treatment may prevent or reduce any UTI complications in pregnancy.

Furthermore, Vitamin D is an essential hormone during pregnancy, and comes from two main sources, either from food or from sun exposures (16). Vitamin D is a known immunomodulator, and deficiency is common in pregnant women (17). Studies have shown some evidence that vitamin D deficiency exposes the urinary tract to infections (18, 19). The urinary tract may not be able produce bactericidal antimicrobial peptides such as human Cathelicidin and β-defensines due to vitamin D deficiency when there is an infection which also increase the UTI severity (18).

In Ghana, previous study has reported significantly high prevalence of vitamin D deficiency even though there is abundance of sunlight (20). Vitamin D deficiency is also more pronounced in pregnant women (17). Thus, the high level of reduced Vitamin D level among pregnant women may predisposes them at greater risk of developing UTI. In addition, asymptomatic UTIs are barely detected among pregnant women in resource limited setting like Ghana due to the cost involved in conducting urine culture tests for every pregnant woman. The is also dearth of data on knowledge and attitude towards UTI among pregnant women. For the first time, this study investigated the prevalence, associated factors and effect of Vitamin D probiotics fortification on asymptomatic UTIs among pregnant women in Ghana.

Study Design

This was a prospective cohort study from the 1st of August 2022 to the 30th of August 2023, where respondents were further grouped into two random groups (control and test). Participants were first recruited, baseline data and samples collected before interventions were administered to the test group. The test group receive vitamin D fortified probiotic yogurt whilst the control group received no special treatments. The participants were then follow-up for 6 months (Fig. 1).

Study Site

The study was conducted at the Ejisu Government Hospital and Juaben Government Hospital in Ejisu-Juaben Municipality in the Ashanti Region of Ghana. The Ejisu-Juaben Municipality is one of Ghana's 30 political and administrative districts, located in the Ashanti Region which is situated in the center of the Ashanti Region and borders six other districts with its main city of Ejisu. The Ejisu Government Hospital and Juaben Government Hospital in the Municipality was chosen because they serve is the major referral centers for the residents and have well-resourced antenatal facility making it suitable for the completion of this study.

Study Population

This study population were pregnant women aged 18 years and above within their first trimester attending antenatal care at the Ejisu Government Hospital and Juaben Government Hospital in the Ashanti region of Ghana.

Inclusion and Exclusion Criteria

This study included pregnant women aged 18 years and above, within their first trimester and without symptoms of UTI attending antenatal care who consented to participate in the study. However, pregnant women below 18 years, with severe pregnancy complications such as diabetes, preeclampsia, hypertension; on special medications; who were admitted to the hospital or had any form of surgical material in their body; and pregnant women who had UTI complaints were excluded from the study.

Sample Size Calculation and Sampling Technique

Using the formula for sample size (n) =

From the metric Table 1g/dL = 10g/l. Using standard deviation estimated to be 1.4g/dL,

Z_α/2 = Z_0.05/2 = Z_0.025 = 1.96 (From Z table) at type 1 error of 5%

Z_ꞵ = Z_0.10 = 1.28 (From Z table) at 90% power

d = effect size; size of the magnitude of change it is desired to be able to detect. This is estimated at 1g/dL.

Minimum sample size (n) = ≈ 41

At 25% Attrition Risk = ≈ 10

Hence, 41 + 10 = 51 participants per group was needed for the study. However, to increase statistical power, 63 pregnant women per group were recruited for the study.

Sampling Technique and Randomization

The pregnant women were recruited by convenience from the Maternity units. A simple probability sampling was used to determine who goes to the test group and goes to the control group. The participants were randomly assigned to control or intervention group base on the hospital they attended the antenatal care. The two hospitals were numbered using one and two (one for intervention, two for control group). The two numbers were folded and randomly selected. The participants from hospital one were in the intervention group and the participants from hospital two were in the control group.

Ethical Consideration

The study protocol was approved by Committee for Human Research Publications and Ethics (CHPRE) at the Kwame Nkrumah University of Science and Technology (KNUST), School of Medical Sciences, Kumasi with reference number CHPRE/AP/260/22 dated 14th June, 2022. Permissions were also obtained from the hospitals (Ejusu Government Hospital and Juabeng Government Hospital) where participants were recruited. Participants were given written informed consent which was read and explained to them in a language they understand to consent before participating in this study. The study was conducted following the guidelines of the Helsinki declaration.

Data Collection Instrument

A well-structured questionnaire was used to collect data from the study participants. The questionnaire was adopted from previous studies (17, 20–22) with geographical based modifications. The questionnaire consisted sections such as sociodemographic and clinical data, knowledge on UTI, attitude towards UTI and previous experiences and practices towards UTI.

Validity and Reliability of Study Questionnaire

To ensure the validity of the developed questionnaire, it was pretested among pregnant women with and without UTI at Onwe Hospital in the Kumasi Metropolis of Ghana to ensure its feasibility to work with. Moreover, the reliability of the questionnaire was determined at Cronbach’s alpha of 0.75.

Formulation of Vitamin Fortified Probiotic Yoghurt

Vitamin D fortified probiotic yogurt was prepared by adding 1.5% of powdered fat milk to skim milk. 100ml of the prepared milk was blended with 90 and 120IU oily form of Vitamin D. The low-fat milk was homogenized at 150 bar pressure (APV1000 laboratory homogenizer). The vitamin D fortified milk was pasteurized and inoculated at 40 to 42 degree Celsius with a starter culture that contained (L. Bulcaricus, S. Thermaphilus, and L. Acidophilus) for 8 hours. The process was stopped when the pH declined to -4. The fortified vitamin D yogurt was packaged in an opaque object and stored at 4 degrees Celsius. The yogurt vitamin D content was tested for stability at day 0, 7 and 14. The stability of vitamin D was very stable at 7 days but depreciated after 7 days. That was the reason why yogurt was prepared and served on a weekly basis to the participants. Vitamin D was not in any way affected by heat treatment.

Sample Collection and Laboratory Analyses

From each participants, 3mL of venous blood samples were collected for biochemical analyses as well as urine samples were collected for urinalyses.

Determination of Serum Vitamin D

Venous blood from the participants were obtained aided by a qualified phlebotomist into serum separator tubes and transported on ice to the Clinical Analysis Laboratory (CAnLab) of the Department of Biochemistry and Biotechnology, KNUST for ELISA using the Multiskan FC (Thermo scientific). Serum levels of 25(OH)D were stratified as deficient (< 20ng/ml) and non-deficient (≥ 20ng/ml).

Determination of Urinary Tract Infection (UTI)

Clean catch midstream urine samples were obtained from the participants and transported on ice to the Microbial Biotechnology Laboratory of the CAnLab, KNUST for urine culture. The samples were inoculated (~ 10ul) on cystine lactose electrolyte deficient (CLED) agar (Oxiod Ltd., UK) and incubated aerobically at 37℃ for 18-24hours. Negative plates were further incubated overnight before reporting whereas bacterial counts of ≥ 1.0x10⁵ CFU/m were reported positive for UTI according to standards. Suspected urine pathogens were isolated for characterization and identification using the Gram stain reaction, culture characteristics, and biochemical tests (Catalase, indole, methyl red, oxidase, coagulase, citrate and triple sugar iron (TSI)).

Scoring and Grading of Knowledge and Attitude Towards UTI Among Study Participants

To assess the level of knowledge on UTI among pregnant women, a total of 24 items structured questions was used. All questions were based on validated questions in previous literature with modifications. Participants were given scores based on their response to the questions. A correct response attracted a score of 1 and a wrong response attracted a score of 0. The maximum score for knowledge level was 24. The participants were classified as having inadequate knowledge if they had a score of 1–12, and participants that had scores 13–24 (≥ 50.0%) were classified as having adequate knowledge on UTI.

Moreover, to assess the level of towards UTI among pregnant women, a total of 9 items structured questions was used. All questions were based on validated questions in previous literature. Participants were given scores based on their response to the questions. A positive response attracted a score of 1 and a negative response attracted a score of 0. The maximum score for attitude was 9. The participants were classified as having poor attitude if they had a score of 0–6, and participants that had scores 7–9 (> 70.0%) were classified as having good attitude.

Data Management and Statistical Analyses

Data collected in the study was entered, cleaned and coded using Microsoft Excel 2021. Statistical analyses were performed using Statistical Package for Social Science (SPSS version 26.0) and GraphPad prism version 8.0. Descriptive analysis was done using measures such as frequency and percentage for categorical variables, means and standard deviations for parametric continuous variables, and median and interquartile ranges for non-parametric continuous variables. Normality test for continuous variables was done using Kolmogorov-Smirnov test. Bar charts and pie charts were used to illustrate the prevalence and proportions of study variables. Chi-square test or Fischer exact test was used to determine the association between categorical variables and study groups. Independent sample t-test was used to compare parametric continuous variables and Mann-Whitney U-Test was used to compare non- parametric continuous variables between cases and controls. In addition, Wilcoxon-Signed Rank test was used to compared baseline and end line levels of Vitamin D and TAC among study groups. Density and box and whiskers plot was also used to compare levels of Vitamin D and TAC among study groups. P-value < 0.05 and 95% confidence interval were considered statistically significant.

Sociodemographic and Clinical Characteristics of Study Participants

This study included 126 pregnant women including 63 each from the Ejisu Government Hospital and Juaben Government Hospital. The mean age of the participants was 27.87 years with most within 17–25 years (35.6%) and 26–30 years (31.0%). Half of the participants had Junior High School (50.0%) education and 23.8% had Senior High School education. Over ninety percentage of the participants were Christians (95.2%). Moreover, more than half were self-employed (54.6%) and 71.1% had monthly income of < Gh₵1,000.00 with average household size of 1–2 (48.8%). In addition, 46.8% and 28.6% had been pregnant twice and thrice respectively; however, 38.1% had given birth once. Most participants were within the second (46.8%) and fisrt (37.9%) trimester (Table 1).

Table 1

Sociodemographic and Clinical Characteristics of Study Participants
Variable	Frequency (n = 126)	Percentage (%)
Facility
Ejisu Government Hospital	63	50.0
Juaben Government Hospital	63	50.0
Age (Years) (π ± SD)	27.87 ± 5.79
Age Group (Years)		-
18–25	46	35.6
26–30	39	31.0
31–35	24	19.0
36–45	17	13.5
Educational Level
Primary	12	9.5
Junior high school	63	50.0
Senior high school	30	23.8
Tertiary	21	16.7
Religion
Christian	120	95.2
Islam	6	4.8
Employment Status
Unemployed	36	28.6
Self-employed	65	54.6
Formally employed	25	19.8
Monthly Income (Gh₵)
< 1000.00	86	71.1
1,000.00-1999.99	24	19.8
2,000.00–4,000.00	11	9.1
Number of Pregnancy
0	3	2.4
1	14	11.1
2	59	46.8
3	36	28.6
4	14	11.1
Number of Children
0	32	25.4
1	48	38.1
2	19	15.1
≥ 3	27	21.4
Household Size
1–2	61	48.8
3–4	39	31.2
5–7	25	20.0
Gestational Age (Weeks)
10–12.	47	37.9
14–26	58	46.8
27–29	19	15.3

Knowledge on UTI Among Pregnant Women

Half of the participants reported that they know about UTI (51.6%), however, only one third responded UTI is an inflammation of the urethra (32.5%), 10.3% responded is inflammation of the bladder, with most who responded neither inflammation of the urethra or bladder (41.3%). In addition, 48.0% responded bacteria is a major cause of UTI whilst 40.8% attributed UTI to be caused by hygiene. The major symptoms of UTI by the respondents were pain in urination (46.3%) and abdominal pain (22.3%). Also, most participants responded that, the factors that increased the chances of UTI were don't care to clean the perineum (35.7%), delay urination (33.3%) and poor personal hygiene (20.6%). Majority responded knew the treatment for UTI (64.3%) and recommended go to the hospital (64.3%) (Table 2).

Acceding to 70.0% cut off-point, only one-third had adequate knowledge on UTI (32.5%) whilst 67.5% had inadequate knowledge know UTI (Fig. 2).

Table 2

Responses to Questions on Knowledge
Variable	Frequency (n = 126)	Percentage (%)
Know UTI
No	61	48.4
Yes	65	51.6
What is UTI?
Inflammation of urethra	41	32.5
Inflammation of bladder	13	10.3
Can be in all of the above	20	15.9
None of the above	52	41.3
Causes of UTI
Bacteria	60	48.0
Protozoa	6	4.8
Fungi	8	6.4
Hygiene	51	40.8
Symptoms of UTI
Pain in urination	56	46.3
Red urine	7	5.8
Abdominal pain	27	22.3
Fever	9	7.4
Back pain	4	3.3
Frequent urination	12	9.9
Urgency	8	6.6
Constipation	1	0.8
Factors that Increases the Chances of Getting UTI
Don't care to clean the perineum	45	35.7
Urination after eating	9	7.1
Drinking large amount water	12	9.5
Drinking little amount water	13	10.3
Delay urination	42	33.3
Poor personal hygiene	26	20.6
Know Treatment for UTI
No	47	37.3
Yes	79	62.7
Treatment for UTI
Go to the hospital	81	64.3
Take rest at home	6	4.8
Take antibiotics directly	10	7.9
Take analgesic	6	4.8
Drink more water	8	6.3
Take more shower	9	7.1

Attitude Towards UTI

Over ninety percentage of participants responded the best way to treat UTI is to go to the hospital (91.3%), however, only 25.0% think UTI is common without 53.2% who responded that UTI is not common. Moreover, 34.9% think UTI infects females more than males, whilst 18.3% think UTI infects males more than females and 30.2% responded think UTI affect males and females equally. Majority responded think UTI is serious (76.0%) and can results in complications such as affects concurrent pregnancy (42.1%), recurrent UTI (28.6%), and affect the quality of life (18.3%). In addition, 39.2% of participants think certain foods prevent UTI (Table 3).

Acceding to 75.0% cut off-point, 70.6% of participants had good attitude towards UTI whilst 29.4% had poor attitude towards UTI (Fig. 3).

Table 3

Responses to Questions on Attitude Towards UTI
Variable	Frequency (n = 126)	Percentage (%)
Best Way to Tackle UTI
Go to the hospital	115	91.3
Take rest at home	6	4.8
Take antibiotics directly	8	6.3
Take analgesic	2	1.6
Drink more water	4	3.2
Take more shower	7	5.6
Think UTI is Common
Yes	31	25.0
No	66	53.2
Don't know	27	21.8
Think UTI Infect Most
Infect females more than males	44	34.9
Infect males more than females	23	18.3
Infect both males and females equally	38	30.2
Don't know	21	16.7
Think UTI is Serious
Yes	92	76.0
No	12	9.9
Don't know	17	14.1
Complications Expected from UTI
Recurrent UTI	36	28.6
Affects concurrent pregnancy	53	42.1
Affect the quality of life	23	18.3
Death	20	15.9
Decrease the weight	22	17.5
Generalized oedema	4	3.2
Think Certain Foods Prevent UTI
Yes	49	39.2
No	76	60.8

Previous UTI Experience and Practices of Pregnant Women

Of the study participants, 21.1% had previously experienced UTI once per year (81.5) or twice per year (18.5%). Most responded experienced symptoms such as pain in urination (84.6%), abdominal pain (48.1%) and frequent urination (30.8%). Moreover, 44.8% responded drink 3–4 bottles of water per day and 20.0% responded drink fluids that irritates the bladder such as coffee and tea. In addition, majority responded go to the hospital (79.2%) when they feel symptoms of UTI, take non-pharmacological aspects such as personal hygiene and healthy diet in UTI treatment seriously (93.1%) and clean the perineum from front and back after using the toilet (85.4%) (Table 4).

Table 4

Previous UTI Experience and Practices of Pregnant Women
Variable	Frequency (n = 126)	Percentage (%)
Experienced UTI
No	97	78.9
Yes	26	21.1
Frequency of Previous UTI
Once per year	22	81.5
Twice per year	5	18.5
Symptoms of UTI Noticed
Pain in urination	22	84.6
Abdominal pain	13	48.1
Fever	3	11.5
Frequent urination	8	30.8
Urgency	5	19.2
Bottles of Water Drink Per Day
1–2.	36	28.8
3–4.	56	44.8
5–6.	26	20.8
≥ 7	7	5.6
Drink Fluids that Irritates the Bladder (Coffee, Tea)
No	100	80.0
Yes	25	20.0
What Do When Feel Symptoms of UTI
Go to the hospital	95	79.2
Take antibiotics directly	17	14.2
Take analgesic	1	0.8
Drink more water	2	1.7
Take more shower	1	0.8
Nothing	4	3.3
Take non-pharmacological (personal hygiene and healthy diet) Aspects in the treatment of UTI seriously
No	7	6.9
Yes	95	93.1
Clean the perineum from front and back after using the toilet	13	14.6
No	76	85.4
Yes

Prevalence of UTI at Among Pregnant Women

This study found that 29.0 of the participants tested positive for UTI representing a prevalence of 23.6% whilst remaining 76.4% were negative for UTI. The isolated bacteria were Escherichia coli (69.0%), staphylococcus spp. (17.2%), Klebsiella pneumoniae (6.9%) and pseudomonas aeruginosa (6.9%) (Fig. 4).

Sociodemographic and Clinical Factors Associated with UTI Among Pregnant Women

This study did not find any significant association between age group (p = 0.809), educational level (p = 0.879), religion (p = 0.564) and UTI. Moreover, employment status (p = 0.859), monthly income (p = 0.164) and household size (p = 0.572) were not significantly associated with UTI. Similarly, number of pregnancies (p = 0.961), children (p = 0.893) and gestational age (p = 0.414) were not significantly associated with UTI among study participants (Table 5).

Table 5

Sociodemographic and Clinical Factors Associated with UTI Among Pregnant Women
		UTI Status
Variable	Total (n = 123)	Negative (n = 94)	Positive (n = 29)	p-value
Facility				0.492
Ejisu Government Hospital	62 (50.4)	49 (52.1)	13 (44.8)
Juaben Government Hospital	61 (49.6)	45 (47.9)	16 (55.2)
Age Group (Years)				0.809
18–25	44 (35.8)	32 (34.0)	12 (41.4)
26–30	38 (30.9)	29 (30.9)	9 (31.0)
31–35	24 (19.5)	20 (21.3)	4 (13.8)
36–45	17 (13.8)	13 (13.8)	4 (13.8)
Educational Level				0.879
Primary	12 (9.8)	10 (10.6)	2 (6.9)
Junior high school	62 (50.4)	48 (51.1)	14 (48.3)
Senior high school	28 (22.8)	21 (22.3)	7 (24.1)
Tertiary	21 (17.1)	15 (16.0)	6 (20.7)
Religion				0.564
Christian	117 (95.1)	90 (95.7)	27 (93.1)
Islam	6 (4.9)	4 (4.3)	2 (6.9)
Employment Status				0.859
Unemployed	35 (28.5)	27 (28.7)	8 (27.6)
Self-employed	63 (51.2)	47 (50.0)	16 (55.2)
Formally employed	25 (20.3)	20 (21.3)	5 (17.2)
Monthly Income (Gh₵)				0.164
< 1000.00	83 (70.3)	66 (74.2)	17 (58.6)
1,000.00-1999.99	24 (20.3)	17 (19.1)	7 (24.1)
2,000.00–4,000.00	11 (9.3)	6 (6.7)	5 (17.2)
Number of Pregnancy				0.961
0	3 (2.4)	2 (2.1)	1 (3.4)
1	13 (10.6)	9 (9.6)	4 (13.8)
2	58 (47.2)	45 (47.9)	13 (44.8)
3	35 (28.5)	27 (28.7)	8 (27.6)
4	14 (11.4)	11 (11.7)	3 (10.3)
Number of Children				0.893
0	30 (24.4)	23 (24.5)	7 (24.1)
1	48 (39.0)	36 (38.3)	12 (41.4)
2	18 (14.6)	13 (13.8)	5 (17.2)
≥ 3	27 (22.0)	22 (23.4)	5 (17.2)
Household Size				0.572
1–2.	58 (47.5)	43 (46.2)	15 (51.7)
3–4.	39 (32.0)	32 (34.4)	7 (24.1)
5–7.	25 (20.5)	18 (19.4)	7 (24.1)
Gestational Age (Weeks)				0.414
10–12.	46 (38.0)	38 (41.3)	8 (27.6)
14–26	57 (47.1)	41 (44.6)	16 (55.2)
27–29	18 (14.9)	13 (14.1)	5 (17.2)

Association Between Knowledge, Attitude and UTI Among Pregnant Women

This study found that, the prevalence of UTI was highest among participants with inadequate knowledge level (82.8%) compared to those with adequate knowledge (17.2%; p = 0.045). Moreover, the prevalence of UTI was predominant among participants with poor attitude (48.3%) compared to good attitude (51.7%; p = 0.015) towards UTI (Fig. 5).

Predictors of UTI Among Pregnant Wowen

In a univariate logistics regression prediction model, compared to adequate knowledge, participants with inadequate knowledge (cOR: 2.85, 95% CI: (1.00-8.14); p = 0.049) was significantly associated with 3-odds increased likelihood of UTI. Similarly, compared to participants with good attitude, those with poor attitude (cOR: 2.88, 95% CI: (1.21–6.86); p = 0.017) was significantly associated with 3-odds increased likelihood of UTI.

In a multivariate logistics regression prediction model, poor attitude (aOR: 3.00, 95% CI: (1.22–7.37); p = 0.017) was independent predictor of increased chances of UTI among pregnant women (Table 6).

Table 6

Predictors of UTI Among Pregnant Wowen
Variable	UTI Positive (n = 29)	cOR (95% CI)	p-value	aOR (95% CI)	p-value
Age Group (Years)
18–25	12 (41.4)	1.22 (0.33–4.48)	0.766	1.50 (0.39–5.85)	0.556
26–30	9 (31.0)	1.01 (0.26–3.88)	0.99	1.12 (0.28–4.55)	0.871
31–35	4 (13.8)	0.65 (0.14–3.07)	0.586	0.67 (0.13–3.37)	0.629
36–45	4 (13.8)	1.00	-	1.00	-
Educational Level
Primary	2 (6.9)	1.00	-	-	-
Junior high school	14 (48.3)	1.46 (0.29–7.45)	0.65	-	-
Senior high school	7 (24.1)	1.67 (0.29–9.52)	0.566	-	-
Tertiary	6 (20.7)	2.00 (0.33–11.97)	0.448	-	-
Number of Pregnancy
0	1 (3.4)	1.00	-	-	-
1	4 (13.8)	0.89 (0.06–12.89)	0.931	-	-
2	13 (44.8)	0.58 (0.05–6.89)	0.664	-	-
3	8 (27.6)	0.59 (0.05–7.42)	0.685	-	-
4	3 (10.3)	0.55 (0.04–8.27)	0.662	-	-
Gestational Age (Weeks)
10–12	8 (27.6)	1.00	-	-	-
14–26	16 (55.2)	1.85 (0.71–8.83)	0.206	-	-
27–29	5 (17.2)	1.83 (0.51–6.59)	0.357	-	-
Knowledge
Adequate knowledge	5 (17.2)	1.00	-	1.00	-
Inadequate knowledge	24 (82.8)	2.85 (1.00-8.14)	0.049	2.72 (0.93–7.96)	0.069
Attitude
Good attitude	15 (51.7)	1.00	-	1.00	-
Poor attitude	14 (48.3)	2.88 (1.21–6.86)	0.017	3.00 (1.22–7.37)	0.017

Effect of Vitamin D Probiotics Fortification on UTI Among Pregnant Women

This study observed that, at baseline, the prevalence of UTI among Vitamin D fortified group was 21.0% and among non-fortified group was 26.2%. However, at endline, the prevalence of UTI among Vitamin D fortified group was 3.2% and among non-fortified group was 16.4%, indicating a drastic effects of Vitamin D fortification in reducing UTI among pregnant women (Fig. 6).

Maternal urinary tract infections (UTIs) remains the commonest nonintestinal infection globally, and it is a major public health concern. Moreover, Vitamin D is a known immunomodulator, and deficiency is common in pregnant women. Few evidence shows vitamin D deficiency may expose the urinary tract to infections. In addition, asymptomatic UTIs are barely detected among pregnant women in resource limited setting like Ghana due to the cost involved in conducting urine culture tests for every pregnant woman. For the first time, this study investigated the prevalence, associated factors and effect of Vitamin D probiotics fortification on asymptomatic UTIs among pregnant women in Ghana. This study finding of 23.6% prevalence of UTI among pregnant women is lower compared to previous study in Northern part of Ghana that reported 39.8% were positive for UTI (22). In another study, prevalence of asymptomatic bacteriuria was respectively 20 and 35.5% among pregnant women at Tamale Central and Tamale Teaching Hospital (23). Other similar studies in Africa have reported varying prevalence rates; 10% in Egypt (24) and 13.3% in Uganda (25). The observed differences in the prevalence rates between the current and previous studies could be attributed to geographical variations, variations in study design, sampling methods, and diagnostic criteria which can significantly impact reported prevalence rates. Besides, the reduced prevalence observed in the current study could be explained as the improved healthcare access and preventive interventions in the study area. Enhanced antenatal care and early screening for UTIs in pregnant women could lead to earlier detection and treatment, thereby lowering the overall prevalence.

Moreover, most isolated bacteria being Escherichia coli (69.0%) and staphylococcus spp. (17.2%) is in-line with previous study in Ghana that Escherichia coli (27.8%) was the commonest isolated bacteria UTI in pregnant women (22). Similarly, studies in other part of Ghana also demonstrated Escherichia coli as the most common UTI among pregnant women (23, 26–28). In UK that the most common agent of UTI is Escherichia coli and is responsible for 68 to 77% of all UTI infections (13). Thus, the consistency between the current study and previous studies underscores the significant role of Escherichia coli as a primary causative agent of UTIs in pregnant women. This study finding reinforce the need for continuous surveillance and tailored interventions to address Escherichia coli as causative agent of UTI in pregnant women.

Furthermore, inadequate knowledge on UTI was significantly associated with 3-odds increased likelihood of UTI, and poor attitude towards UTI was independent predictor of increased chances of UTI among pregnant women. These findings is in consistent with previous studies in Ghana (22), Northeast Ethiopia (29), Philippines (30), United Arab Emirates (31) and Pakistan (32) who also equally found inadequate knowledge and poor attitude were significantly associated with UTI among antenatal women. Thus, the lack of adequate knowledge on UTI regarding the causes, symptoms, and prevention of UTIs among pregnant women may consistently contribute to a higher incidence of infections. Similarly, this study findings shows a negative attitude towards UTI prevention and treatment contributes a significant factor of persistent UTI. Pregnant women who do not prioritize UTI prevention maybe likely to engage in behaviors that increase their risk of infection. These findings underscore the relevant of targeted health education programs for pregnant women. Programs which focus on improving knowledge and fostering positive attitudes towards UTI prevention can significantly reduce the incidence of UTIs.

Interestingly, at end line, the prevalence of UTI among Vitamin D fortified group reduced from 21.0–3.2% and among non-fortified group reduced from 26.2% 16.4%, indicating a drastic effects of Vitamin D fortification in reducing UTI among pregnant women. This study finding is contrary to previous study among Bangladesh pregnant women which reported no significant maternal differences in vitamin D levels were found at delivery between control and intervention groups (33). The difference in the current study compared to Bhowmik et al., could be due to the differences in the interventions administered. As opposed to the current study that used Vitamin D probiotics fortified yoghurt for intervention groups with no special treatment in control group, Bhowmik et al., utilized oral high dose intermittent vitamin D3 supplementation for intervention group and control group received prescribed dietary instruction. The current study findings highlights the important role of Vitamin D in preventing UTIs. This aligns suggest that adequate Vitamin D levels can enhance the immune system's ability to combat infections, including UTIs. This drastic reduction in UTI prevalence at end line due to Vitamin D fortification implies significant public health benefits. It confirms that public health strategies incorporating Vitamin D supplementation could reduce UTI incidences and related healthcare costs. Health education campaigns should also emphasize the importance of Vitamin D in preventing UTIs, encouraging individuals to maintain adequate Vitamin D levels through diet, supplementation, and safe sun exposure.

UTI: Urinary tract infection

TSI: Citrate and triple sugar iron

CLED: Cystine lactose electrolyte deficient

CAnLab Clinical Analysis Laboratory

Acknowledgements

The authors are grateful to study participants, as well as research assistants who contributed in diverse ways to the successful implementation of the study.

Authors' contributions

CA, EO and RA supervised the project; VA, CA, EO and RA were involved in conceptualization and project administration; VA and ES were involved in data curation and statistical analyses; VA, CA, EO, RA and ES were involved in study design, investigation, manuscript drafting and reviewing. All authors have approved the final version of the manuscript.

Data Availability

All data generated or analyzed during this study are included in this article and can be requested from the corresponding author.

Competing Interests

Authors declare that no conflicts of interest exist.

Funding

This study did not receive funding from private, government or non-for-profit organization.

Human Ethics and Consent to Participate Declarations

Not Applicable

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No competing interests reported.

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Prevalence, Predictors and Effect of Vitamin D Probiotics Fortification on Asymptomatic Urinary Tract Infections Among Pregnant Women: A Prospective Cohort Study

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Abstract

Background

Methods

Results

Conclusion

Figures

INTRODUCTION

MATERIALS AND METHODS

Study Design

Study Site

Study Population

Inclusion and Exclusion Criteria

Sample Size Calculation and Sampling Technique

Sampling Technique and Randomization

Ethical Consideration

Data Collection Instrument

Validity and Reliability of Study Questionnaire

Formulation of Vitamin Fortified Probiotic Yoghurt

Sample Collection and Laboratory Analyses

Determination of Serum Vitamin D

Determination of Urinary Tract Infection (UTI)

Scoring and Grading of Knowledge and Attitude Towards UTI Among Study Participants

Data Management and Statistical Analyses

RESULTS

Sociodemographic and Clinical Characteristics of Study Participants

Knowledge on UTI Among Pregnant Women

Attitude Towards UTI

Previous UTI Experience and Practices of Pregnant Women

Prevalence of UTI at Among Pregnant Women

Sociodemographic and Clinical Factors Associated with UTI Among Pregnant Women

Association Between Knowledge, Attitude and UTI Among Pregnant Women

Predictors of UTI Among Pregnant Wowen

Effect of Vitamin D Probiotics Fortification on UTI Among Pregnant Women

DISCUSSION

Conclusion

Abbreviations

Declarations

References

Additional Declarations

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