PREVALENCE OF URINARY TRACT INFECTIONS AMONG PREGNANT WOMEN

ATTENDING KERICHO REFERRAL HOSPITAL.

BY:

SUMÈIYA ABDULLAHI BULLE ADAN.

D/MLS/23007/562.

A RESEARCH PROPOSAL SUBMITTED TO KENYA MEDICAL TRAINING

COLLEGE IN PARTIAL FULFILLMENT FOR THE AWARD OF DIPLOMA IN
MEDICAL LABORATORY & SCIENCES.

KENYA MEDICAL TRAINING COLLEGE,

P.O.BOX 466,
NYERI .

DECLARATION

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I hereby declare that this is my own work. It has not been presented in any other institution for
academic purpose.

RESEARCHER: SUMEIYA ABDULLAHI BULLE.

COLLEGE NO: D/MLS/23007/562.

SIGNATURE…………………………..

DATE…………………………….

SUPERVISOR: MR. JAMES WACHIRA

SIGNATURE: ………………………………………………….

DATE…………………………….

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 DEDICATION
I would like to dedicate this research proposal to my parents for their unconditional love and
support throughout my studies.

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 ACKNOWLEDGEMENT
I thank the Almighty God for giving me the strength to carry out this study. I sincerely thank my
Parents for financial and moral support they have given me during this study and throughout My
life.

Additional to that, Special gratitude goes to my supervisor Mr. James Wachira for the guidance
and support he has given me in writing this research.

Finally i would like to thank the staff members of the Department of Medical Laboratory and
Sciences for giving me the opportunity to study in Kenya Medical Training College--Nyeri
Campus.

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TABLE OF CONTENTS
DECLARATION ............................................................................................................................................1
DEDICATION ............................................................................................................................................... 3
ACKNOWLEDGEMENT .............................................................................................................................. 4
TABLE OF CONTENTS ................................................................................................................................5
LIST OF TABLES ......................................................................................................................................... 7
LIST OF FIGURES ........................................................................................................................................8
LIST OF ABBREVIATIONS ......................................................................................................................... 9
DEFINATION OF TERMS .......................................................................................................................... 10
ABSTRACT ................................................................................................................................................. 11
CHAPTER ONE: INTRODUCTION .............................................................Error! Bookmark not defined.
1.1BACKGROUND INFORMATION ........................................................... Error! Bookmark not defined.
1.2 STATEMENT OF THE PROBLEM .......................................................................................................14
1.3 STUDY JUSTIFICATION ......................................................................................................................15
1.4 RESEARCH QUESTIONS ..................................................................................................................... 16
1.5 OBJECTIVES ........................................................................................................................................ 17
1.5.1 BROAD objective .................................................................................................................................17
1.5.2 SPECIFIC OBJECTIVE ...................................................................................................................... 17
CHAPTER TWO: LITERATURE REVIEW ............................................................................................... 18
2.0 INTRODUCTION ................................................................................................................................... 18
2.1 RISK FACTORS TO UTI IN PREGNANCY ..........................................................................................18
2.1.1 PHYSIOLOGICAL FACTORS ........................................................................................................... 18
2.1.2 SOCIO DEMOGRAPHIC FACTORS ................................................................................................. 19
2.1.3 PAST HISTORY OF UTI ...................................................................................................................19
2.1.4. SEXUAL INTERCOARSE AND CONTRACEPTIVES ...................................................................... 19
2.1.5 URINARY OBSTRUCTION ................................................................................................................20
2.2 EFFECTS OF UTI IN PREGNANCY .....................................................................................................20
2.2.1 on the infant ......................................................................................................................................... 20
2.2.2 on the mother ....................................................................................................................................... 21
2.3 AWARENESS OF UTI IN PREGNANCY .............................................................................................. 21

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2.3.1 Health Education ................................................................................................................................. 21
2.3.2 Screening for UTI in pregnancy ........................................................................................................... 22
CHAPTER THREE STUDY METHODOLOGY ......................................................................................... 22
3.1 STUDY AREA ........................................................................................................................................ 22
3.2 BACKGROUND INFORMATION ......................................................................................................... 22
3.3 ECONOMIC ACTIVITY ........................................................................................................................22
3.4 STUDY DESING .................................................................................................................................... 23
3.5 STUDY POPULATOIN .......................................................................................................................... 23
3.6 INCLUSION AND EXCLUSION CRITERIA .........................................................................................23
3.6.1 Inclusion criteria .................................................................................................................................. 23
3.6.2 Exclusion criteria ................................................................................................................................. 23
3.7 SAMPLING METHOD .......................................................................................................................... 23
3.8 THE SAMPLE SIZE ...............................................................................................................................23
3.9 DATA COLLECTION ............................................................................................................................23
3.10 DATA PRESENTATION AND ANALYSIS ..........................................................................................23
3.11 STUDY LIMITATIONS ....................................................................................................................... 24
3.12 ETHICAL CONSIDERATION ............................................................................................................. 24
CHAPTER FOUR: DATA PRESENTATION .............................................................................................. 24
4.0 INTRODUCTION .................................................................................................................................. 24
4.1 SOCIO DEMOGRAPHIC FACTORS .................................................................................................... 24
4.2 RISK FACTORS OF UTI IN PREGNANCY .......................................................................................... 26
4.3 EFCTS OF UTI IN PREGNANCY ......................................................................................................... 28
4.4 AWARENESS OF UTI IN PREGNANCY .............................................................................................. 31
CHAPTER FIVE DISCUSSION AND INTERPRETATION ........................................................................33
5.0 INTRODUCTION ................................................................................................................................... 33
5.1 SOCIO DEMOGRAPHIC FACTORS .................................................................................................... 33
5.2 RISK FACTORS TO UTI IN PREGNANCY ..........................................................................................34
5.3 EFFECTS OF UTI IN PREGNANCY .....................................................................................................35
5.4 AWARENESS OF UTI IN PREGNANCY .............................................................................................. 36
CHAPTER SIX CONCLUSION AND RECOMMENDATION .................................................................... 36
6.0 INTRODUCTION ................................................................................................................................... 36
6.1 CONCLUSION .......................................................................................................................................36
6.2 RECOMENDATION .............................................................................................................................. 37
REFERENCE ...............................................................................................................................................37
APPENDIX I BUDGET ................................................................................................................................39

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APPENDIX II QUESTIONNAIRE ...............................................................................................................40

LIST OF TABLES

TABLE 4.1 Showing age distribution of respondents

TABLE 4.2 showing the parity of respondents

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LIST OF FIGURES
Figure 4.1 showing the marital status
Figure 4.2 showing educational level
Figure 4.3 showing respondents occupation
Figure 4.4 showing gestational age
Figure 4.5 showing history of contraceptive use
Figure 4.6 showing previous history of UTI
Figure 4.7 showing history of catheterization
Figure 4.8 showing mothers who have given birth to preterm infants
Figure 4.9 showing infants with respiratory distress
Figure 4.10 showing infants with mental retardation
Figure 4.11 showing history of caesarian delivery
Figure 4.12 showing previous history of pre eclampsia
Figure 4.13 showing respondents who previously heard of UTI
Figure 4.14 showing respondents who are aware of signs and symptoms of UTI
Figure 4.15 showing respondents who have been screened for UTI

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LIST OF ABBREVIATIONS

UTI - Urinary tract infection

CS - Caesarian section

KCRH- Kericho County Referral Hospital

AST - Antimicrobial susceptibility testing

ASB- Asymptomatic Bacteriuria

WHO - World Health Organization .

NEW WORDS:: Anorexia---

Caesarian delivery---

Preterm delivery---

Pre-eclampsia---

Pyelonephritis---

Suprapubic pain---

Bilateral flank pain---

Maternal anemic & amniotic--

3rd trimester--

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DEFINATION OF TERMS
Bacteriuria - The presence of bacteria in urine.

Asymptomatic - producing or showing no symptoms

Parity-The number of pregnancy reaching viability

Gestational age-Age of fetus estimated from last menstrual period

Risk factor - Characteristic or exposure of an individual that increases the likelihood of

developing a disease

Effects - Complications, results or consequences

Awareness - knowledge or perception of a situation or fact.

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ABSTRACT
Urinary tract infections in pregnancy are associated with risk of preterm birth and pyelonephritis,
if untreated. The apparent decline in immunity of pregnant women appears to promote the
growth of microorganisms. Women with asymptomatic bacteria in the early pregnancy develop
symptomatic Bacteriuria later in pregnancy.

The incidence of UTI has been steadily increasing over the past few years resulting in upsurge of
cases among pregnant women.

The aim of this study was to assess the risk factors to UTI and identifies its complication as well
as evaluating the awareness among pregnant women attending Kericho Referral Hospital
County.

A cross sectional study design was applied to women who attended the Hospital and
quantitative data was analyzed using tables and pie charts. A total number of 100 pregnant
women of different age groups responded.

Findings of the study provide empirical data on the incidence of urinary tract infection among
pregnant women. The incidence is high among this study population, therefore all pregnant
women should be screened during their first visit to KCRH by urinalysis to detect and treat
Bacteriuria to avoid complications that may ensue in both mother and fetus.

In conclusion it was seen majority of respondents are not aware of urinary tract infection
presentations while most have not been screened for UTI and it was recommended that the

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government should formulate ways to do more screening and carry out health education for
antenatal mothers to improve

CHAPTER ONE: INTRODUCTION

1.1BACKGROUND INFORMATION

Urinary tract infection (UTI) - This is the infection of any part of the urinary system, bladder,
urethra or kidney. UTI is more common in women than men and usually occurs in the bladder
or urethra but more serious infections occur in the kidney.

UTI is among the most common health problems affecting women in their reproductive ages.
Pregnant women are more susceptible to UTI due to a combination of hormonal and physiologic
changes that predispose them to bacteriuria. The incidence of acute pyelonephritis in pregnant
women is also significantly increased.

Factors such as history of recurrent urinary tract infection, diabetes, low socio economic status,
increasing maternal age, multiparty, and anatomical abnormalities of the urinary tract have also
been associated with an increased in bacteriuria during pregnancy.
The general presentation of UTI are divided into two, Symptomatic bacteriuria and
asymptomatic bacteriuria. Globally, the prevalence of UTI in pregnancy ranges between 13% -
33% with symptomatic bacteriuria occurring in 1% - 18% while asymptomatic cases are noted in
2% - 10% of women. The prevalence has remained constant and most of the recent observational
studies, including those from developing countries, report almost similar rates.
The most common agent implicated in both symptomatic and asymptomatic bacteriuria is
Escherichia coli that is responsible for 70% - 80% of the infections.. Past studies indicate that
UTI among pregnant mothers in Kenya range from 10% - 19%.

UTI has the second most complications in pregnancy after anemia and if not managed well it can
adversely affect the health status of both the mother and her unborn child. Studies have indicated
that 25% - 40% of untreated pregnant women with asymptomatic bacteriuria will eventually
develop to acute pyelonephritis as the most common cause of preterm delivery hospitalization
which increases the risk mortality and the number of infants with low-birth weights. Other
complications include premature rupture of fetal membranes, respiratory failure, anemia and risk

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of septicemia and shock. Moreover, children born with mothers with pyelonephritis are much
more prone to impairment of mental and motor development

UTI can lead to serious obstetric complications, including poor maternal and perinatal outcomes
such as intrauterine growth restriction, pre-eclampsia, caesarean delivery, and preterm delivery.
Consequently, early diagnosis of UTI, proper management, and an appropriate therapeutic and
preventive approach are very important measures to prevent complications during pregnancy.

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1.2 STATEMENT OF THE PROBLEM
Routine urine culture is not carried out even for antenatal mothers. Currently, most patients are
treated empirically without culture and antimicrobial susceptibility testing (AST) and treatment
is therefore based on empiric guidelines that are rarely updated.

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1.3 STUDY JUSTIFICATION
UTI is one of the most common health problems affecting pregnant women and it’s among the
leading cause of infant morbidity and mortality.
Several physiological, anatomical, and personal factors contribute to this problem during
pregnancy, such as urethral dilation, increased bladder volume, and decreased bladder tone with
urinary stasis. Also, some unsound personal hygiene increases the risk of infection.
Currently in Kenya routine urine culture is not done to diagnose UTI, even where UTI tests are
done, only dipstick analysis and direct wet microscopy of urine are used, these tests have poor
predictive values to detect bacteriuria particularly in asymptomatic person.
Over reliance on these methods and absence of culture and susceptibility testing have partially
led to under-diagnosis of UTI and this may be fuelling the rising cases of treatment failure.
The study is aimed at creating awareness and improving the knowledge of urinary tract infection
during pregnancy to establish adequate preventive, diagnostic and treatment measures. Finally,
this study is a requirement for partial fulfillment of my diploma course in Clinical Medicine and
Surgery.

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1.4 RESEARCH QUESTIONS

1]Are there risk factors loading to urinary tract infection during pregnancy?
2]Are there effects of urinary tract infection in pregnancy?
3]Are pregnant women aware of urinary tract infection during pregnancy?

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1.5 OBJECTIVES

1.5.1 BROAD OBJECTIVE

To determine the incidence of UTI among pregnant women attending at Kericho County Refferal
Hospital.

1.5.2 SPECIFIC OBJECTIVE

a)To assess the risk factors leading to UTI in pregnancy.
b)To identify the effects of UTI in pregnancy.
c)To evaluate the awareness of UTI in pregnancy.

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CHAPTER TWO: LITERATURE REVIEW

2.0 INTRODUCTION
This chapter presents review of literature of scholars with regards to specific objectives.

2.1 RISK FACTORS TO UTI IN PREGNANCY

Risk factor-Any attribute, characteristic or exposure of an individual that increases the
likelihood of developing a disease. The following factors can lead to infection of the urinary tract
in women during pregnancy.

2.1.1 PHYSIOLOGICAL FACTORS

Pregnancy causes numerous changes in the women’s body. Hormonal and mechanical changes.
Increase the risk of urinary stasis and the retrograde flow of urine from the bladder to the kidney
(Alvarez et al., 2010).

These changes along with an already short urethra and difficulty with hygiene due to the
distended pregnant abdomen, these are more evident as the gestational age increases. In general,
pregnant patients are considered immunocompromised UTI hosts because of the physiologic
changes associated with pregnancy.

These changes increase the risk of serious infectious complications from symptomatic and
asymptomatic urinary infection (Alvarez et al., 2009).Various maternal physiological and
anatomic factors predispose to ascending infection. Such factors include urinary retention caused
by the weight of the enlarging uterus and urinary stasis due to progesterone-induced ureteral
smooth muscle relaxation. Blood volume expansion is accompanied by increase in the
glomerular filtration rate and urinary output (Celen et al., 2011)

Loss of ureteral tone in pregnant women combined with increased urinary tract volume results in
urinary stasis, which can lead to dilatation of the uterus renal pelvis and calyces.

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Urinary stasis and the presence of backward flow of urine from the bladder into the kidneys
predispose some pregnant women to upper urinary tract infections and acute nephritis (Coulthard
et al., 2010).

2.1.2 SOCIO DEMOGRAPHIC FACTORS

Several patient social demographic factors are associated with an increased frequency of urinary
tract infections during pregnancy. Compared with high social economic status women, patients
with low socio-economic status have an increased incidence of asymptomatic bacteriuria
(Hamdan et al., 2011)

Other risk factors include diabetes mellitus, multiparty, neurogenic bladder retention, history of
backward flow of urine from the bladder into the kidneys (treated or untreated) , previous renal
transplantation, (Ghafari et al.,2008) and a history of previous infections of ascending
colonization of the urinary tract, primarily by existing vaginal, perineal, and fecal flora (Celen et
al.,2011)

2.1.3 PAST HISTORY OF UTI

Two strongest predictors of UTI in prenatal care are identified to be antepartum UTI prior to
prenatal care and a past urinary tract infection during pregnancy (Berard et al., 2011).

2.1.4. SEXUAL INTERCOARSE AND CONTRACEPTIVES

Sexually active women are at a greater risk of UTI than women who do not engage in sexual
intercourse. Pregnant women who evidently engage in sexual activity increase the chances of
bacterial contamination which leads to asymptomatic urinary tract infections. Having sexual
intercourse may also cause asymptomatic

UTIs in women because bacteria can be pushed into the urethra (Olaitan et al, 2006). Specific
risk related to sexual intercourse include frequency (four or more times per week), the use of
spermicides that may alter vaginal pH and thus affect its flora and engagement with the new
sexual partner (Roberts, et al 2000).

Contraceptive use affects the rate of UTI, which appears to be greater in Women who use certain
types of spermicides or diaphragm (Gupta and Trautner,2013), certain types of contraceptives
can also increase the risk of UTIs.

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Women who use diaphragms tend to develop UTIs. The spring-rim of the diaphragm can bruise
the area near the bladder, making it susceptible to bacterial infection (Hazhir 2007). Diaphragms
push against the urethra and make it more difficult to completely empty the bladder. The urine
that stay in the bladder is more likely to allow growth of bacteria and cause infections (Hooton
and Thomas, 2010). Spermicidal foam used with diaphragms, and spermicidial-coated condoms,
also increase susceptibility to UTIs. Most spermicides contain nonoxynol-9, [a chemical whose
side effects are associated with UTI (Gupte and Trautner, 2013).】

2.1.5 URINARY OBSTRUCTION

A foreign body in the urinary system may act as an infection and may be associated with a
current active infection (Ann and Kieran, 2010). A Common examples includes urinary calculi
and indwelling catheters.

Urinary Catheters are associated with chronic bacterial colonization, which occurs in almost all
patients after five to seven days. This colonization significantly increases the risk for
symptomatic bacteriuria(Jacobsen et al., 2008). Catheter modifications antibiotic and silver
impregnation have been developed in an effort to decrease the rate of infection in patients with
indwelling catheters(Jacobsen et al, 2006).

2.2 EFFECTS OF UTI IN PREGNANCY

Effects-complications, results or consequences

UTI has a lot of complications in pregnancy and if not managed well it can adversely affect the
health status of both the mother and her unborn child.

2.2.1 ON THE INFANT..

Women with asymptomatic bacteriuria during pregnancy are more likely to deliver premature or
low-weight infants.

. These pregnant women also have an increased risk of developing pyelonephritis; compared
with women without bacteriuria (Hooton and Thomas, 2010). Subsequently, pulmonary edema
and acute respiratory distress syndrome develop (Hazhir, 2007).

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Other complications may include the following; perinephric cellulitis and abscess, septic shock,
and renal dysfunction. Moreover, children born with mothers with pyelonephritis are much more
prone to impairment of mental and motor development (Gupta et al, 2011).

2.2.2 ON THE MOTHER ..

UTI can lead to serious obstetric complication such as pre-eclampsia, cesarean delivery, and
preterm delivery maternal and perinatal outcomes such as intrauterine growth restriction
complications, including, (Gupta et al., and 2011).

Untreated UTI is associated with low birth weight, prematurity, premature labor, hypertension,
pre-eclampsia, maternal anemic and amnionitis(Hill et al., 2005).

2.3 AWARENESS OF UTI IN PREGNANCY

Awareness---knowledge or perception of situation or fact...

2.3.1HEALTH EDUCATION
The knowledge and understanding of urinary tract infection among pregnant women during
pregnancy is very low.

Health care workers should provide health education to pregnant women on predisposing factors,
complications and possible presentation of UTI in pregnancy during Antenatal visits.

The presentation of UTI varies according to whether the patient has asymptomatic bacteriuria, or
symptomatic bacteriuria (Cai et al., 2012).

Burning with urination (dysuria) is the most significant symptom in pregnant women with
symptomatic (Colgan and William, 2011).

This burning is not experienced in asymptomatic bacteriuria therefore enabling undetected

disease progression.

Other symptoms include frequency and urgency of passing urine, suprapubic pain, and hematuria
in the absence of system symptoms of pyelonephritis symptoms on presentation vary, they often

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include fever(>38°C)shaking chills, cost vertebral angle tenderness, anorexia, nausea, and
vomiting. Right-sided flank pain is more common than left-side or bilateral flank pain.

Additional to that Patients may also present with hypothermia (as low as (34°C).(Gupta et
al.,2011).

2.3.2 SCREENING FOR UTI IN PREGNANCY

UTI is one of the most common bacterial infections occurring during pregnancy. Lack of
diagnosis during pregnancy remains the major issue for asymptomatic bacteriuria screening
bacteriuria by mid-stream urine culture should be performed during the first Antenatal visit and
repeated in the third trimester, as status may change throughout pregnancy (Colgan R, et
al .2005).This would help improve the possible complications and effects of UTI on both the
mother and child

CHAPTER THREE ::STUDY METHODOLOGY

3.1 STUDY AREA

The study was done at kericho County Refferal Hospital..

3.2 BACKGROUND INFORMATION

The study was conducted in Kericho County Referral Hospital. The area covered by kericho
subcounty [AINAMOI] location is approximately 43 4 km square and has a population of
31,004 (according to the 2009 census) people of different races with Kalenjin community of the
Kipsigis sub tribe being the majority.

3.3 ECONOMIC ACTIVITY

Farming was the main economic activity of the local community, crops cultivated for
consumption and trade include sugarcane, sorghum, beans, cassava and maize. Some households
practice poultry farming, goats, sheep and cattle keeping.

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3.4 STUDY DESIGN
A descriptive study of cross-section design was adapted by the researcher.
The researcher selected this type of design to carry out the study easily, faster and be able to
determine complete and accurate information.

3.5 STUDY POPULATOIN

The target population were pregnant women who are coming for check-up at Kericho County
Refferal Hospital.

3.6 INCLUSION AND EXCLUSION CRITERIA

3.6.1 INCLUSION CRITERIA.

The study includes all pregnant women attending antenatal clinic at Kericho County Referral
Hospital

3.6.2 EXCLUSION CRITERIA

All patients except gravid women at KCRH [ Kericho County Referral Hospital]

3.7 SAMPLING METHOD

The sampling method used was simple random sampling.

3.8 THE SAMPLE SIZE

The researcher used a small sample size due to limited time and resources.
The researcher desired to have 100 respondents in this study since above factors needed to be
considered.

3.9 DATA COLLECTION

Data was collected through structured questionnaires where respondents pick one answer that
best suits for their situation.

3.10 DATA PRESENTATION AND ANALYSIS

The data presentation was in form of tables and pie charts since it is easy to interpret.

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3.11 STUDY LIMITATIONS
The research study duration was short, there were instances of language barrier during data
collection.

3.12 ETHICAL CONSIDERATION

The study approval was sought from the Dean's office in Kenya medical training college ,Nyeri
campus through the department of Medical Laboratory and Sciences. Participation was voluntary
and informed consent was obtained from each participant prior to administering the
questionnaires. All data obtained was treated as confidential with no identity details collected.

CHAPTER FOUR: DATA PRESENTATION

4.0 INTRODUCTION
This chapter presents findings of data collected from the field.

4.1 SOCIO DEMOGRAPHIC FACTORS

TABLE 4.1 Showing age distribution of respondents

Distribution
under 21 12%
21-25 35%
26-30 32%
31-35 16%
Over 35 5%
Most (35%) were between ages 21-25 while the least (5%) were over 35 years

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