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Sexually transmitted infections and associated factors during pregnancy in Gondar city, Northwest Ethiopia, 2021: A multicenter study

Open AccessPublished:June 23, 2022DOI:https://doi.org/10.1016/j.cegh.2022.101096

      Abstract

      Background

      Sexually transmitted infections are one the most important public health problems in the developing countries that have been reported to have many adverse pregnancy outcomes. Despite the adverse pregnancy outcomes, studies on the prevalence and associated factors of sexual transmitted infection among pregnant women in Ethiopia, especially in our study setting are scarce. Therefore, this study aimed to assess the prevalence and associated factors of sexually transmitted infection among pregnant women in Gondar city, Ethiopia.

      Methods

      An institution-based cross-sectional study was conducted among 507 pregnant women who were attending antenatal care in public health facilities in Gondar city from September 1 to 30, 2021. A systematic random sampling technique was used to select the study participants and data were collected using pretested and interviewer-administered questionnaire. Data were entered using Epi-data version 4.6 and cleaned, and analyzed using SPSS version 25 software. Multivariable logistic regression model was used to determine factors associated with sexual transmitted infection among pregnant women. Adjusted odds ratio (AOR) with 95% of confidence interval and p value < 0.05 were used to declare the significant variables.

      Results

      A total of 507 pregnant women were included in this study, and making a response rate of 97.3%. The prevalence of sexually transmitted infections among pregnant women was 15.2% (95% CI: 12.1%, 18.3%). Being rural resident (AOR = 2.96, 95% CI: 1.43, 6.12), having history of stillbirth (AOR = 2.68, 95% CI: 1.08, 6.68), having history of sexually transmitted infections (AOR = 2.77, 95% CI: 1.10, 7.01) and husbands suspected of having other sexual partners (AOR = 4.73, 95% CI: 2.16, 10.38) were significantly associated with sexually transmitted infections.

      Conclusion

      In this study, sexually transmitted infections were a public health problems because one sixth of pregnant women experienced sexually transmitted infections. Pregnant women with the identified factors need special focus to tackle the problem and its negative health consequences. Moreover, it is better to provide community-based education programmes focusing on changes to sexual behavior for male to tackle this public health important problem.

      Keywords

      1. Introduction

      Sexually transmitted infections (STIs) are defined by a variety of clinical syndromes caused by pathogens that can be acquired and transmitted from one person to another through unprotected sexual activity.
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      Sexually transmitted infections: evidence brief: world Health Organization.
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      • Mabey D.
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      More than a million people acquire STIs every day, with an estimated 499 million new cases of curable STIs occur every year.
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      Sexually Transmitted Infections (STIs): The Importance of a Renewed Commitment to STI Prevention and Control in Achieving Global Sexual and Reproductive Health.
      The prevalence of STIs among pregnant women varies from country to country. In 2016, 53.6% pregnant women in Papua New Guinea was infected with at least one STIs.
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      In 2018 and 2021 in South Africa, the prevalence of STIs was 41%
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      Prevalence, incidence and associated risk factors of STIs during pregnancy in South Africa.
      respectively. More than half (53.6%) of pregnant women in Gambia were infected with STIs during 2021.
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      A study conducted in Kenya in 2017 also found that 20.8% of pregnant women had acquired STIs.
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      In Ethiopia, the prevalence of STIs among pregnant women was 19.1% in Southwest Ethiopia
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      Sexually transmitted infection associated syndromes among pregnant women attending antenatal care clinics in southwest Ethiopia.
      during 2021 and 26.6% in central Ethiopia
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      during 2017.
      STIs compromise quality of life, as well as sexual and reproductive health, and newborn and child health. STIs during pregnancy have major consequences for the mothers and infants.
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      Sexually transmitted infections in pregnancy: prevalence, impact on pregnancy outcomes, and approach to treatment in developing countries.
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      • et al.
      Prevalence, risk factors and adverse pregnancy outcomes of second trimester bacterial vaginosis among pregnant women in Bukavu, Democratic Republic of the Congo.
      STIs has a significant association with a number of adverse pregnancy and neonatal outcomes, such as spontaneous abortion,
      • Mullick S.
      • Watson-Jones D.
      • Beksinska M.
      • Mabey D.
      Sexually transmitted infections in pregnancy: prevalence, impact on pregnancy outcomes, and approach to treatment in developing countries.
      prematurity,
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      Chlamydia trachomatis and adverse pregnancy outcomes: meta-analysis of patients with and without infection.
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      • et al.
      Chlamydia trachomatis infection during pregnancy associated with preterm delivery: a population-based prospective cohort study.
      • Faruqui A.
      Bacterial vaginosis: risk of adverse pregnancy outcome.
      premature rupture of membranes,
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      Adverse pregnancy and neonatal outcomes associated with Neisseria gonorrhoeae: systematic review and meta-analysis.
      perinatal mortality,
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      ,
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      • Broutet N.
      • Hawkes S.J.
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      stillbirth and low birth weight.
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      • Bisimwa G.
      • et al.
      Prevalence, risk factors and adverse pregnancy outcomes of second trimester bacterial vaginosis among pregnant women in Bukavu, Democratic Republic of the Congo.
      ,
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      • Balaram K.
      • Hackney D.N.
      Chlamydia trachomatis and adverse pregnancy outcomes: meta-analysis of patients with and without infection.
      ,
      • Johnson H.L.
      • Ghanem K.G.
      • Zenilman J.M.
      • Erbelding E.J.
      Sexually transmitted infections and adverse pregnancy outcomes among women attending inner city public sexually transmitted diseases clinics.
      Untreated STIs during pregnancy also increase the risk of miscarriage, stillbirth, neonatal deaths, prematurity, low birth weight, and congenital syphilis.
      • Gomez G.B.
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      • Mark J.
      • Broutet N.
      • Hawkes S.J.
      Untreated maternal syphilis and adverse outcomes of pregnancy: a systematic review and meta-analysis.
      ,
      • Qin J.
      • Yang T.
      • Xiao S.
      • Tan H.
      • Feng T.
      • Fu H.
      Reported estimates of adverse pregnancy outcomes among women with and without syphilis: a systematic review and meta-analysis.
      ,
      • Kuznik A.
      • Habib A.G.
      • Manabe Y.C.
      • Lamorde M.
      Estimating the public health burden associated with adverse pregnancy outcomes resulting from syphilis infection across 43 countries in sub-Saharan Africa.
      STIs increase the risk of human immunodeficiency virus (HIV) transmission, human papilloma virus infection, infertility, physical, psychological, and social consequences.
      • Who
      The Importance of a Renewed Commitment to STI Prevention and Control in Achieving Global Sexual and Reproductive Health.
      Syphilis in pregnancy leads to over 143,000 early fetal deaths and stillbirths, 61,000 neonatal deaths, 41,000 preterm or low-birth weight births, and 109,000 infants with clinical congenital syphilis.
      • Korenromp E.L.
      • Rowley J.
      • Alonso M.
      • et al.
      Global burden of maternal and congenital syphilis and associated adverse birth outcomes—estimates for 2016 and progress since 2012.
      Several factors associated with STIs during pregnancy have been identified in different parts of the world. Most importantly, maternal age,
      • Davey D.J.
      • Peters R.P.H.
      • Kojima N.
      • et al.
      Sexual behaviors of human immunodeficiency virus–infected pregnant women and factors associated with sexually transmitted infection in South Africa.
      • Nyemba D.C.
      • Medina-Marino A.
      • Peters R.P.H.
      • et al.
      Prevalence, incidence and associated risk factors of STIs during pregnancy in South Africa.
      • Isara A.
      • Baldeh A.-K.
      Prevalence of sexually transmitted infections among pregnant women attending antenatal clinics in West Coast Region of the Gambia.
      ,
      • Sultan S.
      • Rachwani K.
      Study of sexually transmitted infections in pregnant women and its effects on pregnancy outcome.
      residency,
      • Sultan S.
      • Rachwani K.
      Study of sexually transmitted infections in pregnant women and its effects on pregnancy outcome.
      marital status,
      • Nyemba D.C.
      • Medina-Marino A.
      • Peters R.P.H.
      • et al.
      Prevalence, incidence and associated risk factors of STIs during pregnancy in South Africa.
      ,
      • Yosef T.
      Sexually transmitted infection associated syndromes among pregnant women attending antenatal care clinics in southwest Ethiopia.
      educational status,
      • Aboyeji A.P.
      • Nwabuisi C.
      Prevalence of sexually transmitted diseases among pregnant women in Ilorin, Nigeria.
      occupational status,
      • Davey D.J.
      • Peters R.P.H.
      • Kojima N.
      • et al.
      Sexual behaviors of human immunodeficiency virus–infected pregnant women and factors associated with sexually transmitted infection in South Africa.
      having multiple sexual partners,
      • Aguilar G.
      • Estigarribia G.
      • Ortiz A.
      • et al.
      Prevalence of syphilis and related risk behaviors among women in 5 distinct indigenous populations in Paraguay.
      ,
      • Anjulo A.A.
      • Abebe T.
      • Hailemichael F.
      • Mihret A.
      Seroprevalence and risk factors of herpes simplex virus-2 among pregnant women attending antenatal care at health facilities in Wolaita zone, Ethiopia.
      alcohol use,
      • Davey D.J.
      • Peters R.P.H.
      • Kojima N.
      • et al.
      Sexual behaviors of human immunodeficiency virus–infected pregnant women and factors associated with sexually transmitted infection in South Africa.
      history of spontaneous abortion,
      • Yosef T.
      Sexually transmitted infection associated syndromes among pregnant women attending antenatal care clinics in southwest Ethiopia.
      and parity
      • Isara A.
      • Baldeh A.-K.
      Prevalence of sexually transmitted infections among pregnant women attending antenatal clinics in West Coast Region of the Gambia.
      ,
      • Hokororo A.
      • Kihunrwa A.
      • Hoekstra P.
      • et al.
      High prevalence of sexually transmitted infections in pregnant adolescent girls in Tanzania: a multi-community cross-sectional study.
      are some of the factors that are significantly associated with STIs.
      Despite studies have been conducted on the negative consequences of STIs on pregnant women and their unborn babies, a large portion of infected women do not seek medical care. According to the 2016 Demographic Health Survey of Ethiopia, only 33% of women who were infected with STIs in the 12 months prior to the survey had health-seeking behavior.
      • Ethiopia F.D.R.
      Ethiopia Demographic and Health Survey 2016. Addis Ababa Ethiopia, and Rockville.
      In Ethiopia, pregnant women are routinely screened for syphilis, HIV and hepatitis B and C by etiologic diagnosis approach during the first ANC visit.
      • FMOH E.
      Management Protocol on Selected Obstetrics Topics for Hospitals.
      To the best of our knowledge, there is no sufficient evidence on the prevalence and its associated factors in our study area. Therefore, this study aimed to assess the prevalence and associated factors of STIs among pregnant women who attending Antenatal Care (ANC) in public health institutions in Gondar city, Ethiopia.

      2. Methods

      2.1 Study design and period

      A multicenter institutional based cross-sectional study was conducted from September 1/2021 to September 30/2021 in public health facilities in Gondar city.

      2.2 Study setting

      This study was conducted among pregnant women who attend antenatal care at public health facilities in Gondar city. Gondar city is located 727 km away from Addis Ababa, the capital city of Ethiopia, and 175 km from Bahir Dar, the capital city of Amhara National Regional State. Gondar city has one public comprehensive specialized hospital and eight health centers (HC) serving the people of Gondar city and the surrounding districts. From a facility-based report in 2013, 8 health institutions had a combined case flows of 432,191 population.

      2.3 Source and study population

      The source population for this study was all pregnant women who attending ANC in public health facilities in Gondar city. All pregnant women who attending ANC from the selected public health facilities in Gondar city and were available at the time of data collection were the study population for this study.

      2.4 Sample size determination and sampling procedure

      The sample size was determined using the single population proportion formula, considering the following assumptions: The proportion of STIs among pregnant women from the previous study was 19.1%,
      • Yosef T.
      Sexually transmitted infection associated syndromes among pregnant women attending antenatal care clinics in southwest Ethiopia.
      level of confidence 95%, and margin of error 5%. Therefore, the sample size, n =Z2p(1P)d2=(1.96)20.191(10.191)0.052 = 237. By multiply the design effect of 2 and adding a 10% non-response rate, the total sample size was 521. From nine public health facilities, Gondar University comprehensive specialized hospital, and three HCs such as Belajig HC, Maraki HC, and Teda HC were randomly selected. The total sample size was proportionally allocated for each selected public health facility depending on their client flow. Systematic sampling technique was used to select the study participants. By using the formula, considering N (total number of pregnant women attending ANC in the selected public health facilities) which is 3155 in one month, n (the required minimum sample size is 521) and k-interval (K = N/n =>3155/521 = 6.05 ≈ 6). The first participant was selected randomly, and the rest were selected every 6th interval.

      2.5 Study variables

      The dependent variable of this study was STIs, which was a binary outcome variable coded as “0″ if a pregnant woman did not present with any syndrome, and “1″ if a pregnant woman presented with at least one of the following syndromes: vaginal discharge, genital ulcer or sores, lower abdominal pain, and inguinal bubo syndromes.
      • Yosef T.
      Sexually transmitted infection associated syndromes among pregnant women attending antenatal care clinics in southwest Ethiopia.
      Whereas residence, maternal age, maternal education, religion, marital status, maternal occupation, husband education, husband occupation, parity, gravidity, multiple sexual partners, history of stillbirth, history of STIs, history of abortion, husband having multiple sexual partners, drinking of alcohol, chat chewing, and condom utilization were independent variables. The syndromic diagnosis approach was used to measure the outcome variable. The syndromic diagnosis approach is one of the simple, rapid, and inexpensive STI screening approaches to the identification of clinical syndromes and giving treatment targeting all the locally known pathogens that can cause the syndrome.
      • Health FDRoEMo
      National guidelines for the management of sexually transmitted infections using syndromic approach.

      2.6 Data collection tool and quality assurance

      The data collection tool was developed by reviewing different literature.
      • Davey D.J.
      • Peters R.P.H.
      • Kojima N.
      • et al.
      Sexual behaviors of human immunodeficiency virus–infected pregnant women and factors associated with sexually transmitted infection in South Africa.
      • Nyemba D.C.
      • Medina-Marino A.
      • Peters R.P.H.
      • et al.
      Prevalence, incidence and associated risk factors of STIs during pregnancy in South Africa.
      • Isara A.
      • Baldeh A.-K.
      Prevalence of sexually transmitted infections among pregnant women attending antenatal clinics in West Coast Region of the Gambia.
      ,
      • Yosef T.
      Sexually transmitted infection associated syndromes among pregnant women attending antenatal care clinics in southwest Ethiopia.
      ,
      • Sultan S.
      • Rachwani K.
      Study of sexually transmitted infections in pregnant women and its effects on pregnancy outcome.
      ,
      • Aboyeji A.P.
      • Nwabuisi C.
      Prevalence of sexually transmitted diseases among pregnant women in Ilorin, Nigeria.
      ,
      • Hokororo A.
      • Kihunrwa A.
      • Hoekstra P.
      • et al.
      High prevalence of sexually transmitted infections in pregnant adolescent girls in Tanzania: a multi-community cross-sectional study.
      Data were collected using a structured questionnaire through face-to-face interview. The questionnaire was prepared in the English version and translated to the local language (Amharic) and back to English to keep its consistency. Four BSc and 2 MSc midwives were recruited for data collection and supervision, respectively. To assure the quality, a one day training was given for data collectors and supervisors about the objective of the study, interview technique and supervising the data process. Besides, pretest was done on 5% of the determined sample size in the Maksegnit HC to look for the understandability and appropriateness of the study tool. The completeness of the questionnaire was checked by the supervisors daily.

      2.7 Data management and analysis

      Data were entered into Epi Data version 4.6 and exported to SPSS version 25 software for cleaning, coding, and further analysis. We used descriptive statistics like frequency, mean, and proportion to present participants’ characteristics. Binary logistic regression analysis was fitted, and variables having a p-value of ≤0.2 in bivariable logistic regression were included in the multivariable logistic regression analysis. In the multivariable logistic regression analysis, a p-value of <0.05 with a 95% CI for the adjusted odds ratio was used to declare significant association between the outcome variable and independent variables. The goodness-of-fit of the model was tested by Hosmer and Lemeshow and was found fit. Multi-collinearity was also checked using the variance inflation factor (VIF) and indicates that there was no multi-collinearity since all variables have VIF <2.

      2.8 Ethical considerations

      Ethical clearance was obtained from the School of Midwifery on behalf of the University of Gondar institutional review board (Reference number: MIDW/106/2021). Written informed consent was taken from each study participant after a clear explanation of the aim of the study. Moreover, there were no any personal identifiers included in the data.

      3. Results

      3.1 Sociodemographic characteristics of the study participants

      A total of 507 pregnant women were included in this study, making a response rate of 97.3%. Of these, 386 (76.1%) of pregnant women were urban residents and majority (74.3%) of pregnant women were Orthodox Christian religion followers. Among the total pregnant women, 305 (60.2%) were aged 25–34 years, and the mean age of the respondents was 28.7 years old (±SD 5.2). The majority (89.3%) and (80.7%) of the pregnant women were married and formally educated, respectively (Table 1).
      Table 1Sociodemographic characteristics of pregnant women who attending ANC in public health facilities in Gondar city, Northwest Ethiopia, 2021.
      VariableCategorySTIsPercentageP-value
      YesNo
      Maternal Age18–24

      25–34

      35–49
      17 (15.0%)

      41 (13.4%)

      19 (21.3%)
      96 (85.0%)

      264 (86.6%)

      70 (78.7%)
      113 (22.3%)

      305 (60.2%)

      89 (17.6%)
      0.180
      ResidenceUrban

      Rural
      42 (10.9%)

      35 (28.9%)
      344 (89.1%)

      86 (71.1%)
      386 (76.1%)

      121 (23.9%)
      0.000
      ReligionOrthodox Christian

      Muslim

      Other*
      62 (16.4%)

      12 (10.0%)

      3 (30.0%)
      315 (83.6%)

      108 (90.0%)

      7 (70.0%)
      377 (74.3%)

      120 (23.7%)

      10 (2.0%)
      0.260
      Marital statusUnmarried

      Married
      13 (24.1%)

      64 (14.1%)
      41 (75.9%)

      389 (85.9%)
      54 (10.7%)

      453 (89.3%)
      0.050
      Maternal education statusNot formally educated

      Educated
      25 (25.5%)

      52 (12.7%)
      73 (74.5%)

      357 (87.3%)
      98 (19.3%)

      409 (80.7%)
      0.002
      Maternal occupationUnemployed

      Employed
      44 (17.0%)

      33 (13.3%)
      215 (83.0%)

      215 (86.7%)
      259 (51.1%)

      248 (48.9%)
      0.250
      Husband education statusNot formally educated

      Educated
      12 (20.7%)

      52 (13.2%)
      46 (79.3%)

      343 (86.8%)
      58 (12.8%)

      395 (87.2%)
      0.120
      Husband occupationUnemployed

      Employed
      20 (26.3%)

      44 (11.7%)
      56 (73.7%)

      333 (88.3%)
      76 (16.8%)

      377 (83.2%)
      0.001
      * Protestant/Catholic/Jew.

      3.2 Behavioral, sexual and reproductive health related characteristics

      Of the total 507 pregnant women, 362 (71.4%) women were multigravida. About 74 (20.0%) and 46 (13.0%) had a history of abortion and still birth, respectively. Regarding multiple sexual partners, 89% of pregnant women did not have multiple sexual partners. The majority (92.7%) of pregnant women did not have a history of STIs (Table 2).
      Table 2Behavioral, sexual and reproductive health related characteristics of pregnant women who attending ANC in public health facilities in Gondar city, Northwest Ethiopia, 2021.
      VariableCategorySTIsPercentageP-value
      YesNo
      GravidityPrim-gravida

      Multigravida
      18 (12.4%)

      59 (16.3%)
      127 (87.6%)

      303 (83.7%)
      145 (28.6%)

      362 (71.4%)
      0.271
      ParityNulliparous

      Primiparous

      Multipara
      21 (13.7%)

      20 (14.3%)

      36 (16.8%)
      132 (86.3%)

      120 (85.7%)

      178 (83.2%)
      154 (30.2%)

      140 (27.6%)

      214 (42.2%)
      0.675
      History of abortionYes

      No
      22 (29.7%)

      55 (12.7%)
      52 (70.3%)

      378 (87.3%)
      74 (20.4%)

      433 (79.6%)
      0.000
      History of stillbirthYes

      No
      22 (45.8%)

      55 (12.0%)
      26 (54.2%)

      404 (88.0%)
      48 (13.0%)

      459 (87.0%)
      0.000
      History of STIsYes

      No
      15 (40.5%)

      62 (13.2%)
      22 (59.5%)

      408 (86.8%)
      37 (7.3%)

      470 (92.7%)
      0.000
      Chat chewingYes

      No
      2 (28.6%)

      75 (15.0%)
      5 (71.4%)

      425 (85.0%)
      7 (1.4%)

      500 (98.6%)
      0.320
      Alcohol drinkingYes

      No
      13 (22.4%)

      64 (14.3%)
      45 (77.6%)

      385 (85.7%)
      58 (11.4%)

      449 (88.6%)
      0.103
      Multiple sexual partnerYes

      No
      11 (19.6%)

      66 (14.6%)
      45 (80.4%)

      385 (85.4%)
      56 (11.0%)

      451 (89.0%)
      0.325
      Husband have multiple sexual partnersYes

      No
      16 (39.0%)

      48 (11.7%)
      25 (61.0%)

      364 (88.3%)
      41 (9.1%)

      412 (90.9%)
      0.000
      Condom utilizationYes

      No
      4 (20.0%)

      73 (15.0%)
      16 (80.0%)

      414 (85.0%)
      20 (3.9%)

      487 (96.1%)
      0.541

      3.3 Prevalence of sexually transmitted infections among pregnant women

      The overall prevalence of STIs among pregnant women was 15.2% (95% CI: 12.1%, 18.3%). Regarding STIs syndrome, 4.9% (95% CI: 3.0%, 6.8%) of pregnant women had vaginal discharge, 5.1% (95% CI: 3.2%, 7.1%) genital ulcer, 6.5% (95% CI: 4.1%, 8.7%) lower abdominal/pelvic pain, and 2.4% (95% CI: 1.0%, 3.7%) inguinal bubo (Fig. 1).
      Fig. 1
      Fig. 1Sexually transmitted infection syndromes among the sampled pregnant women at selected public health facilities in Gondar city, Northwest Ethiopia, 2021.

      3.4 Factors associated with sexually transmitted infections

      In the final multivariable logistic model, four variables were significantly associated with STIs. The odds of experiencing STIs among rural resident pregnant women were 2.96 (AOR = 2.96, 95% CI: 1.43, 6.12) times higher compared to urban resident. Pregnant women with history of stillbirth and STI had 2.68 times (AOR = 2.68, 95% CI: 1.08, 6.68) and 2.77 times (AOR = 2.77, 95% CI: 1.10, 7.01) higher odds of experiencing STI than pregnant women who did not have history of still birth and STI, respectively. Furthermore, the odds of having STIs were 4.73 (AOR = 4.73, 95% CI: 2.16, 10.38) times higher among pregnant women whose husband have multiple sexual partners than pregnant women whose husband who have not multiple sexual partners (Table 3).
      Table 3Bivariable and multivariable logistic regression analysis of factors associated with sexually transmitted infections among pregnant women who attending ANC in public health facilities in Gondar city, Northwest Ethiopia, 2021.
      VariableCategoryCORP-valueAORP-value
      Maternal age18–24

      25–34

      ≥35
      0.65 (0.32, 1.35)

      0.57 (0.31, 1.05)

      1
      0.247

      0.070
      1.44(0.55, 3.74)

      0.90 (0.41, 1.99)

      1
      0.457

      0.839
      ResidencyUrban

      Rural
      1

      3.33 (2.01, 5.53)
      0.0001

      2.96 (1.43, 6.12)
      0.003
      Marital statusUnmarried

      Married
      1.93 (0.98, 3.80)

      1
      0.0581.80 (0.67, 4.84)

      1
      0.126
      Maternal education statusNo formal education

      Educated
      2.35 (1.37, 4.03)

      1
      0.0020.81 (0.35, 1.86)

      1
      0.623
      History of abortionYes

      No
      2.91 (1.64, 5.16)

      1
      0.0001.51 (0.67, 3.44)

      1
      0.080
      History of stillbirthYes

      No
      6.23 (3.30, 11.72)

      1
      0.0002.68 (1.08, 6.68)

      1
      0.034
      History of STIsYes

      No
      4.49 (2.21, 9.11)

      1
      0.0002.77 (1.10, 7.01)

      1
      0.031
      Alcohol drinkYes

      No
      1.74 (0.89, 3.40)

      1
      0.1071.09 (0.47, 2.51)

      1
      0.839
      Husband have multiple sexual partnersYes

      No
      4.85 (2.42, 9.73)

      1
      0.0004.73 (2.16, 10.38)

      1
      0.000

      4. Discussion

      Our study assessed the prevalence and associated factors of STIs in pregnant women who were attending ANC in public health facilities in Gondar city, Northwest Ethiopia. Based on our assessment, STIs is a public health problem and the risk factors for having STIs include rural residency, pregnant women whose husband having multiple sexual partners, having a history of STI and still birth. The prevalence of STI among pregnant women was 15.2% (95% CI: 12.1%, 18.3%), which is higher than a study done in Nepal 8.6%.
      • Dev R.
      • Adhikari S.P.
      • Dongol A.
      • et al.
      Prevalence assessment of sexually transmitted infections among pregnant women visiting an antenatal care center of Nepal: pilot of the World Health Organization's standard protocol for conducting STI prevalence surveys among pregnant women.
      The possible variations might be differences in the sociodemographic characteristics of the study population. Thus, almost all of the study participants (96.4%) in Nepal were educated, which may have provided an opportunity for them to practice preventive behavior by accessing information as compared to uneducated women, since 19.3% of women in the present study did not have formal education. . In addition, in this study, 10.7% of women were unmarried, but a study done in Nepal was conducted among married pregnant women. Being unmarried might increase the risk of being infected with STIs as compared to married pregnant women. This justification is supported by different studies conducted elsewhere.
      • Yosef T.
      Sexually transmitted infection associated syndromes among pregnant women attending antenatal care clinics in southwest Ethiopia.
      ,
      • Ginindza T.G.
      • Stefan C.D.
      • Tsoka-Gwegweni J.M.
      • et al.
      Prevalence and risk factors associated with sexually transmitted infections (STIs) among women of reproductive age in Swaziland.
      ,
      • Williams C.L.
      • Harrison L.L.
      • Llata E.
      • Smith R.A.
      • Meites E.
      Sexually transmitted diseases among pregnant women: 5 states, United States, 2009–2011.
      In our study, 24.1% and 14.1% of unmarried and married women were infected with STIs, respectively.
      On the other hand our study finding is lower than studies conducted in Southwest Ethiopia 19.1%,
      • Yosef T.
      Sexually transmitted infection associated syndromes among pregnant women attending antenatal care clinics in southwest Ethiopia.
      Kenya 20.8%,
      • Masha S.C.
      • Wahome E.
      • Vaneechoutte M.
      • Cools P.
      • Crucitti T.
      • Sanders E.J.
      High prevalence of curable sexually transmitted infections among pregnant women in a rural county hospital in Kilifi, Kenya.
      Gambia 53.6%,
      • Isara A.
      • Baldeh A.-K.
      Prevalence of sexually transmitted infections among pregnant women attending antenatal clinics in West Coast Region of the Gambia.
      Tanzania 49.4%
      • Hokororo A.
      • Kihunrwa A.
      • Hoekstra P.
      • et al.
      High prevalence of sexually transmitted infections in pregnant adolescent girls in Tanzania: a multi-community cross-sectional study.
      and Thailand 28.1%.
      • Suvanna Asavapiriyanont M.D.
      • Chaovarindr U.
      • Kaoien S.
      • Chotigeat U.
      • Kovavisarach E.
      Prevalence of sexually transmitted infection in teenage pregnancy in Rajavithi Hospital, Thailand.
      The possible discrepancy might be the difference of the study population and method of diagnosis approach. In our study, we used a syndromic approach as the method of diagnosis, which might lead to underreporting of STIs due to a failure to report asymptomatic pregnant women. In contrast, studies conducted in Tanzania, Gambia, and Thailand used a clinical diagnosis approach using blood, urine, and high vaginal swabs samples, which provides more confidence in reporting STIs by clinically examining all pregnant women, including those who are asymptomatic. Besides, the study population for a study done in Thailand was teenage pregnant women, but in our study we included all reproductive aged pregnant women. STIs are more common among the teenage population as compared to their counterparts.
      • Nyemba D.C.
      • Medina-Marino A.
      • Peters R.P.H.
      • et al.
      Prevalence, incidence and associated risk factors of STIs during pregnancy in South Africa.
      ,
      • Ginindza T.G.
      • Stefan C.D.
      • Tsoka-Gwegweni J.M.
      • et al.
      Prevalence and risk factors associated with sexually transmitted infections (STIs) among women of reproductive age in Swaziland.
      ,
      • Lan P.T.
      • Lundborg C.S.
      • Phuc H.D.
      • et al.
      Reproductive tract infections including sexually transmitted infections: a population-based study of women of reproductive age in a rural district of Vietnam.
      ,
      • Tadesse E.
      • Teshome M.
      • Amsalu A.
      • Shimelis T.
      Genital Chlamydia trachomatis infection among women of reproductive age attending the gynecology clinic of Hawassa University Referral Hospital, Southern Ethiopia.
      Regarding factors associated with experiencing STIs, living in rural areas was significantly associated with increased odds of experiencing STIs among pregnant women. It contradicts with a study reported in Sub Saharan Africa
      • Dadzie L.K.
      • Agbaglo E.
      • Okyere J.
      • et al.
      Self-reported sexually transmitted infections among adolescent girls and young women in sub-Saharan Africa.
      and consistent with a study conducted in Tanzania.
      • Manyahi J.
      • Jullu B.S.
      • Abuya M.I.
      • et al.
      Prevalence of HIV and syphilis infections among pregnant women attending antenatal clinics in Tanzania, 2011.
      This might be explained by the fact that pregnant women who reside in rural areas may have less access to information about the risks of STIs as well as poor health seeking behavior. This may translate to non-utilization of preconception STIs diagnosis and treatment services, increasing the chance of acquisition of STI during pregnancy.
      • Basera T.J.
      • Takuva S.
      • Muloongo K.
      • Tshuma N.
      • Nyasulu P.S.
      Prevalence and risk factors for self-reported sexually transmitted infections among adults in the Diepsloot informal settlement, Johannesburg, South Africa.
      In this study, history of stillbirth was significantly associated with higher odds of experiencing STIs among pregnant women. The possible justification could be that the previous still birth might have been caused by either an undiagnosed, diagnosed but not treated, or diagnosed and treatment started but not completed, STI. This indicates that the STIs was subclinical during the inter-pregnancy period, which manifests during the current pregnancy.
      Consistent with previous studies,
      • Yosef T.
      Sexually transmitted infection associated syndromes among pregnant women attending antenatal care clinics in southwest Ethiopia.
      ,
      • Anjulo A.A.
      • Abebe T.
      • Hailemichael F.
      • Mihret A.
      Seroprevalence and risk factors of herpes simplex virus-2 among pregnant women attending antenatal care at health facilities in Wolaita zone, Ethiopia.
      this study revealed that history of STIs was significantly associated with the experience of STIs among pregnant women. Pregnant women with history of STIs had higher odds of STIs as compared to their counterparts. This might be due to unprotected sex with untreated positive sexual partners, relapse, inappropriate treatment or poor adherence to treatment, and resistance of antimicrobial drugs to STIs treatment increase the chance of infected with STI.
      • Plummer E.
      • Vodstrcil L.
      • Fairley C.
      • et al.
      O02. 2 the Impact of Concurrent Partner Treatment for Bacterial Vaginosis on the Genital Microbiota of Heterosexual Couples: A Pilot Study.
      ,
      • Thurman A.R.
      • Holden A.E.C.
      • Shain R.N.
      • Perdue S.
      • Piper J.M.
      Preventing recurrent sexually transmitted diseases in minority adolescents: a randomized controlled trial.
      Moreover, husbands who suspected to have other sexual partner was strongly associated with the development of STIs. Husband who suspected to have another sexual partners had higher odds of experiencing STIs compared to their counterparts. The possible explanation is the fact having multiple sexual partner is a risk factor for experiencing STIs
      • Anjulo A.A.
      • Abebe T.
      • Hailemichael F.
      • Mihret A.
      Seroprevalence and risk factors of herpes simplex virus-2 among pregnant women attending antenatal care at health facilities in Wolaita zone, Ethiopia.
      ,
      • Menéndez C.
      • Castellsagué X.
      • Renom M.
      • et al.
      Prevalence and risk factors of sexually transmitted infections and cervical neoplasia in women from a rural area of southern Mozambique.
      because if husband who have unprotected sexual intercourse with another sexual partner and getting STIs from others, which leads to increasing experiencing STIs among the pregnant women. Lastly, this study used a multicenter public health institutions and probability sampling technique, which increases the generalizability of the study findings. As a limitation, we used a syndromic approach for the diagnosis of the outcome variable, which does not truly reflect the prevalence of STIs because the approach misses asymptomatic cases. Furthermore, the prevalence of STIs may be underestimated due to sensitivity, social desirability bias, and feelings of shame in reporting their syndromes.

      5. Conclusions

      This study revealed that STIs was prevalent among pregnant women, indicating that it is a significant public health problem in our study setting. Study participants who were from a rural area, had history of STIs and stillbirth, and husband who had multiple sexual partners were found to be factors that significantly increase the risk of being infected with STIs among pregnant women. Therefore, it is better to give special attention for pregnant women with the identified risk factors to avert the problem. In addition to the one-time diagnosis of syphilis and HIV during the first ANC visit, it is better to emphasize the syndromic diagnosis approach of STIs for pregnant women during each ANC visit to prevent adverse pregnancy and birth outcomes. Besides, community-based education programmes focusing on changes to sexual behavior are better to tackle this public health problem.

      Funding

      The research was not supported by any grant.

      Authors’ contributions

      NTT was involved in the conception and design of the study, participated in data collection, analyzed the data, drafted the manuscript, and approved the final version of the manuscript. BA, TE, TA, MK, TTH, ATS, KYW, and ME approved the proposal with some revisions, participated in data analysis, and revised subsequent drafts of the manuscript, and approved the last version of the manuscript. All authors have read and approved the manuscript.

      Data sharing statement

      The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

      Consent to publish

      Not applicable.

      Declaration of competing interest

      The authors declare that they have no competing interests.

      Acknowledgments

      We are very gratitude to the University of Gondar for approval of the ethical clearance. Our grateful also goes to the School of Midwifery, public health facilities, data collectors, supervisors, and study participants.

      Abbreviations

      AOR
      Adjusted Odds Ratio
      ANC
      Antenatal Care
      CI
      Confidence Interval
      COR
      Crude Odds Ratio
      HC
      Health Care
      SPSS
      Statistical Package for Social Science
      STIs
      Sexually Transmitted Infections

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