Abstract
Purpose
The purpose of this study was to examine the association between hygiene and sexual practices and the incidence of urinary tract infection (UTI) among Jordanian pregnant women.
Methods
The cross-sectional data were collected using self- administered survey from October 2018 to January 2019 in central Jordan. A total of 200 pregnant women completed the survey. All of them were married and aged between 18 and 45 years (M = 27.45; SD = 6.06). The measures used were demographics, social, hygiene and sexual practices.
Results
A significant association was found between the incidence of UTI and the educational level of husbands (p = 0.05), history of UTI in previous pregnancies (p = 0.02) and being in the second trimester of pregnancy (p = 0.02). Their sexual and hygiene practices also were significantly associated with the incidence of UTI.
Conclusion
History of UTI in previous pregnancies, hygiene and sexual practices are associated with increased incidence of UTI among Jordanian pregnant women. Appropriate strategies and techniques to promote health and preventive behaviors for pregnant women with UTI should be provided to improve the quality of life among pregnant women and reduces economic burdens on health care system.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12884-024-06902-4.
Keywords: Urinary tract infection, Sexual practices, Hygiene practices, Pregnant women, Jordan
Introduction
Urinary tract infections (UTIs) are among the most common infections in clinical practice worldwide [1]. It is a major public health problem, particularly among pregnant women in developing countries, and it has adverse effects on mothers and newborns [2]. The American Urological Association defines UTIs as “a combination of pathogen(s) within the urinary system and symptoms and/or inflammatory response to pathogen(s) requiring treatment” [3]. A UTI during pregnancy is classified as two symptomatic or asymptomatic. Symptomatic UTI present with dysuria, frequency, suprapubic discomfort, and hematuria. Asymptomatic bacteriuria, as the name implies, is an infection without symptoms that occurs in 2–15% of pregnancies [4]. The most common bacteria is Escherichia coli (E. coli), which originates from the bowel [5]. Other organisms such as Staphylococcus saprophyticus, Klebsiella, Proteus, Pseudomonas, Enterobacter, Enterococcus, and Candida in the order of frequency also cause UTIs [6]. Risk factors for UTI include congenital abnormalities of the urinary tract, a history of diabetes (especially under an insulin regimen), previous catheterization, urinary tract calculi, spinal cord injuries, neurological disorders, pelvic organ prolapse, and pelvic floor trauma [7].
Women are more prone to develop UTIs due to the anatomy of the urinary system, as the urethra is short and in close proximity to the anus and vagina, facilitating the migration of enteral bacteria into the urinary tract [2]. Pregnant women are at a higher risk of recurrent bacteriuria and acute pyelonephritis owing to physiological changes during pregnancy. The hormonal fluctuation that occurs between the sixth and seventh weeks of gestation relaxes the ureteral muscle, leading to ureteral dilatation, which may occur around 10 weeks of gestation and worsen throughout pregnancy [8]. In addition, an enlarged uterus between 22 and 26 weeks of gestation may increase pressure on the bladder, thereby increasing urine stasis [9, 10]. Other changes include elevated urine pH, increased amino acid excretion, decreased urine concentration, and the presence of glycosuria [11] also contribute to the occurrence of UTIs.
The existing literature has identified the risk factors for UTIs in pregnant women, including age, gestational age, parity, anemia, incomplete bladder emptying, history of UTIs, and low socioeconomic status [2]. Other risk factors for UTIs related to sexual practices and hygiene behaviors have also been reported [2]. Sexual practices that contributed to UTIs include not washing the genitals before and after intercourse by women and their spouses, not urinating before and after intercourse, and not taking a bath after coitus [2, 12]. Inadequate personal hygiene behaviors found in the literature include washing the genitalia from back to front, using non-cotton underwear, using soap for the vaginal area, not drying genitals after washing, and not changing underwear on a regular basis [13, 14]. UTIs during pregnancy have negative consequences for mothers, fetuses, and newborns. Affected mothers have a higher risk of premature rupture of membranes, recurrent UTIs, urethral narrowing, intrauterine growth restriction (IUGR), premature births, and low birth weight infants [2]. Untreated or poorly treated UTIs adversely affect maternal and fetal well-being, which is associated with an increase in the morbidity of mother and fetus. For instance, cystitis, pyelonephritis, pregnancy-induced hypertension, preeclampsia, anemia, recurrent abortion, endometritis, amnionitis, chorioamnionitis, cystitis, and pyelonephritis may complicate renal failure, sepsis, and shock [8].
The global prevalence of UTI varies. Nearly 74% of pregnant women in some low-middle income countries (LMICs) develop asymptomatic bacteriuria (ASB), and 45% of untreated ASB develop pyelonephritis [15]. In Jordan, almost 20% of the overall morbidity (41.3%) during the antenatal period is related to UTIs, which is higher than that in other high- or low-income countries [16].
Jordan has established policies to screen for and treat UTIs, such as routine urine tests three times during pregnancy and routine antibiotic prescriptions when the urine culture test confirms an infection. However, data from Jordan show a high rate of UTI during pregnancy [17, 18] and a high rate of premature births, which is probably a common complication of UTI. In Jordan, the neonatal mortality rate is 14.1 per 1000 live births, 76% of which are early neonatal deaths [19]. Prematurity and low birth weight are the second most common causes of neonatal mortality after respiratory and cardiovascular disorders [19–22]. One way to address premature births and the associated mortality is to address the occurrence of UTIs during pregnancy [23, 24]. It is important to explore the factors that contribute to the occurrence of UTIs so that appropriate interventions can be provided. These factors might be due to a lack of knowledge about appropriate sexual practices and hygiene behaviors among pregnant women.
Providing evidence of the associated risk factors for UTIs would convince policymakers, health administrators, and professionals (midwives, nurses, and doctors) to implement various strategies to promote health and preventive behaviors in pregnant women. This would improve the quality of health services and decrease the rates of maternal and neonatal mortality and morbidity associated with UTIs, thereby increasing the cost of health services.
Research on UTIs in pregnant women in Jordan is limited. Additionally, studies on the association between UTIs, hygiene, and sexual practices have not been conducted. Therefore, this study aimed to examine Jordanian pregnant women’s sexual and hygiene practices and their association with the occurrence of UTIs.
This study was designed to answer the following research questions:
What are the sexual and hygiene practices of pregnant Jordanian women who attended four maternal health centers in Jordan?
Is there an association between Jordanian pregnant women’s sociodemographic data, obstetric history, hygiene and sexual practices, and UTI occurrence?
Methods
Design
A descriptive, cross-sectional, correlational design was used to collect data on the hygiene and sexual practices of pregnant women. A correlational design was used to assess and describe the relationship between all variables at a specific time without any manipulation of this relationship [25].
Setting
The study was conducted in four maternal health centers in Zarqa, Central Jordan. These health centers provide maternal and child health services; dental services; emergency services; and obstetric, medical, and pediatric specialists. The standard of care for UTIs in these health centers includes routine urine tests thrice during pregnancy and antibiotics for a positive urine culture test. However, there are no available structured health education programs for these pregnant women. These sites were chosen for feasibility and researcher access for a large number of pregnant women.
Participants
The inclusion criteria were as follows: participants must be Jordanian pregnant women, aged between 18 and 45 years, able to read and write Arabic, and willing to participate in the study. Pregnant women with documented congenital abnormalities in the urinary system, urological disease, or kidney transplants were excluded. For nursing studies, utilizing a minimum power of 0.80 enables the study to detect differences or relationships that exist in the population [25]. Based on power analysis for the calculation of sample size with anticipated significance at 0.05 level (alpha = 0.05) and the power level at 0.80 with a medium effect size [26], the minimum required total sample size was 200 women, and the sample size for each group was 100 pregnant women. Recruitment continued until a matched sample of the completed dataset was obtained.
The total number of pregnant women who attended during the study period was 510. In total, 282 women who met the inclusion criteria were recruited. The researcher used a convenience sampling technique to recruit participants into two groups: pregnant women with a UTI (UTI group) and those without a UTI (non-UTI group).In our study, there was an 82 incomplete questionnaires, that’s a result of refused the participants to answer many questions especially those related to sexual practices, although before data collection we explained for the participants the aim of this study and its questionnaire, the majority of women said " these questions was personal and we didn’t expect it to exist”. These 82 participants were excluded from the study.
Instrument
A structured questionnaire was used to collect the data. This instrument was developed by researchers. The questionnaire consisted of five parts: [1] demographics, obstetric and gynecological history such as the last menstrual period (LMP), expected date of delivery (EDD), and gestational age; [2] signs and symptoms of UTI experienced by the women at the time of UTI diagnosis, such as fever, tachycardia, low back pain, and flank pain; [3] women’s sexual practices, such as the number of times of intercourse per week; [4] hygiene practices, such as frequency of changing underwear per week, frequency of urination per day, number of baths per week, and number of cups of water consumed per day; and [5] data and results of urine analysis, urine culture, and the use of antibiotics. The instrument was translated from English to Arabic and reverse translated from Arabic to English by bilingual experts. Some modifications (adding, deleting, and rephrasing certain questions) were made to suit the Jordanian culture. Five experts in obstetric health nursing determined the validity of the content to test the relevance and competence of the tools. The content validity index (CVI) was 0.93, which is considered highly valid. The Cronbach’s alpha was 0.643. A pilot study was conducted on 20 pregnant women to test the content, applicability, clarity, and time required to complete the questionnaire. Structured questionnaire attached at the end of the paper.
Data collection procedures and ethical considerations
This study was approved by the Institutional Review Board of Jordan University of Science and Technology (No. 45/116/2018) and the Jordanian Ministry of Health (No. 8103). The consent that was obtained from all of the participants was informed. Thereafter, the purpose of the study and data collection procedures were explained to the managers of each health center. Data were collected two days a week (Saturday to Thursday) from each clinic (rotation) over a period of four months from October 1, 2018, to January 31, 2019, and data were collected from the two clinics on the same day due to their proximity. The researcher explained the purpose of the study, risks and benefits, voluntary nature of participation, and the ability to withdraw from the study at any time without consequences to the participants. Participants were assured that all information would be kept confidential and stored in a safe place accessible only to the research team. Women who agreed to participate in the study signed the consent form prior to completion of the questionnaire (in Arabic), which took approximately 15 min to complete. Completed hard copies of the questionnaire were collected and stored in a locked cabinet in the principal investigator’s office.
Data analysis
Descriptive statistics, including the frequency, mean, and SD, were used to describe the sample. A chi-square test was used to explore the relationship between occurrence of UTI (categorical variable) and all categorical data collected (educational level for women and their husband, women work, husband work, smoking cigarette, drinking coffee, etc.….).
The independent t test was conducted to compare means of continuous variables of data collected between two groups ( UTI group and non-UTI group), theses data include the number of the baths, the number of times of intercourse per week, the number of times of changing underwear per week, the number of water cups consumed per day, and the number of times of urinating per day. The results for each statistical method are shown in the corresponding tables throughout the text. It was accepted that the level of significance would be 0.05 for the whole study. All data were analyzed using Statistical Package for the Social Sciences (SPSS) software, version 25 (SPSS v 25) (IBM, 2017).
Results
Comparison of the UTI group and the non-UTI group
Two hundred (200) pregnant women participated in this study. All participants were married and aged between 18 and 45 years (M = 27.45; SD = 6.06). Participants were divided into two groups: pregnant women with a UTI (UTI Group; n = 100, 50%) and those without a UTI (non-UTI group; n = 100, 50%). Detailed information on the demographic data is presented in Table 1.
Table 1.
Sociodemographic characteristics of the participants by study group
| UTI %(n) |
Non UTI %(n) |
Comparison between groups (Chi-Square test) | |||
|---|---|---|---|---|---|
|
Age Mean (SD): 27.45 (6.06) |
< 19 | 9(9) | 8(8) | X2 = 4.21 (p = 0.52) | |
| 20–24 | 29(29) | 22(22) | |||
| 25–29 | 31(31) | 37(37) | |||
| 30–34 | 18(18) | 13(13) | |||
| 35–39 | 12(12) | 17(17) | |||
| > 40 | 1(1) | 3(3) | |||
| Mother’s educational level | Primary | 1(1) | 0(0) | X2 = 1.20 (p = 0.87) | |
| Preparatory | 15(15) | 13(13) | |||
| Secondary | 15(15) | 16(16) | |||
| High school | 44(44) | 45(46) | |||
| BA or more | 25(25) | 26(26) | |||
| Husband’s educational level | Illiterate | 0(0) | 1(1) | X2 = 10.70 (p = 0.05) | |
| Primary | 2(2) | 2(2) | |||
| Preparatory | 16(16) | 11(11) | |||
| Secondary | 26(26) | 15(15) | |||
| High school | 42(42) | 41(41) | |||
| BA or more | 14(14) | 30(30) | |||
| Smoking cigarette | Yes | 4(4) | 5(5) | X2 = 0.12 (p = 0.73) | |
| No | 96(96) | 95(95) | |||
| Smoking Narghile | Yes | 18(18) | 16(16) | X2 = 0.14 (p = 0.70) | |
| No | 82(82) | 84(84) | |||
| Employment | Work | 19(19) | 25(25) | X2 = 1.05 (p = 0.3) | |
| Doesn’t work | 81(81) | 75(75) | |||
| Coffee consumption | Drink | 46(46) | 47(47) | X2 = 0.02 (p = 0.89) | |
| Doesn’t drink | 54(54) | 53(53) | |||
| Trimester of pregnancy | First | 2(2) | 10(10) | X2 = 7.09 (p = 0.02) | |
| Second | 51(51) | 39(39) | |||
| Third | 47(47) | 51(51) | |||
| History of UTI in pregnancy | 40% (40) | 57% (57) | X2 = (p = 0.02) | ||
| Husband age | 33.08(SD = 7.67) | 32.76(SD-0.65) | t = 0.318 (p = 0.75) | ||
| Total household income | 348.05 (SD = 152.87) | 381.80 (SD = 156.49) | t = -1.543 (p = 0.12) | ||
| Number of cigarettes | 0.32 (SD = 1.86) | 0.5 (SD = 2.59) | t= -0.564 (p = 0.57) | ||
| Number of cups of coffee | 0.8 (SD = 1.04) | 0.78 (SD = 1.04) | t = 0.138 (p = 0.89 ) | ||
| Gravidity | 2.89 (SD = 1.79) | 3.19 (SD = 1.82) | t= -1.177 (p = 0.24) | ||
| Parity | 1.63 (SD = 1.62) | 1.91 (SD = 1.60) | t= -1.232 (p = 0.22) | ||
| Miscarriage | 0.3 (SD = 0.67) | 0.28 (SD = 67) | t = 0.211 (p = 0.83) | ||
| HB level | 11.51 (SD = 1.24) | 11.67 (SD = 0.9) | t= -1.038 (p = 0.30) | ||
Sexual practices for UTI and non-UTI groups
The sexual habits of the UTI and non-UTI groups were also compared. An independent t-test was conducted to compare the means of the continuous variables of data collected between the two groups (UTI and non-UTI groups), which included the number of intercourses per week. There were significant differences in the mean number of intercourse sessions per week between the UTI group (M = 2.98; SD = 1.45) and the non-UTI group (M = 2.02; SD = 0.85; t = 5.69 (198), p ≤ 0.001). For example, about 58% of the women in the UTI group urinated after intercourse compared to 97% of those in the non-UTI group (p ≤ 0.001). See Table 2.
Table 2.
Comparisons between the UTI group (N = 100) and the non-UTI group’s (N = 100) sexual practices
| UTI %(n) |
Non UTI %(n) |
Comparison between groups | ||
|---|---|---|---|---|
| Urinate before coitus | Yes | 45(45) | 92(92) | X2 = 51.18 (p = 0.00) |
| No | 55(55) | 8(8) | ||
| Urinate after coitus | Yes | 58(58) | 97(97) | X2 = 43.61 (p = 0.00) |
| No | 42(42) | 3(3) | ||
| Women wash their genitals before coitus | Yes | 91(91) | 99(99) | X2 = 6.74 (p = 0.00) |
| No | 9(9) | 1(1) | ||
| Women wash their genitals after coitus | Yes | 99(99) | 100(100) | X2 = 1.00 (p = 0.32) |
| No | 1(1) | 0(0) | ||
| Husbands wash their genitals before coitus | Yes | 72(72) | 95(95) | X2 = 19.20 (p = 0.00) |
| No | 28(28) | 5(5) | ||
| Husbands wash their genitals after coitus | Yes | 97(97) | 100(100) | X2 = 3.05 (p = 0.08) |
| No | 3(3) | 0(0) | ||
| Women have bath directly after coitus | Yes | 73(73) | 88(88) | X2 = 7.17 (p = 0.00) |
| No | 27(27) | 12(12) | ||
| Women use vaginal spray before coitus | Yes | 10(10) | 1(1) | X2 = 7.79 (p = 0.00) |
| No | 90(90) | 99(99) | ||
| Women use vaginal cream before coitus | Yes | 31(31) | 4(4) | X2 = 25.25 (p = 0.00) |
| No | 69(69) | 96(96) | ||
| Use genital fresheners before coitus | Yes | 49(49) | 18(18) | X2 = 21.57 (p = 0.00) |
| No | 51(51) | 82(82) | ||
Hygiene practices between the UTI group and the non-UTI group
A chi-square test was performed to compare hygiene practices between the two groups. There were significant differences in the average number of changes in underwear per week between the UTI (M = 8.68; SD = 4.4) and non-UTI groups (M = 10.43; SD = 4.76; t = -2.69 (198), p = 0.01). See Tables 3 and 4 for details description of these practices.
Table 3.
Hygiene practices: comparison of UTI group (N = 100) and non-UTI group (N = 100)
| UTI %(n) |
Non UTI % (n) |
Comparison between groups | ||
|---|---|---|---|---|
| Direction of washing genitals | Front to back | 94(94) | 95(95) | X2 = 0.09 (p = 0.76) |
| back to front | 6(6) | 5(5) | ||
| Washing hand before and after urination | Yes | 94(94) | 100(100) | X2 = 6.19 (p = 0.01) |
| No | 6(6) | 0(0) | ||
| Dry genitals after washing | Yes | 84(84) | 97(97) | X2 = 9.83(p = 0.00) |
| No | 16(16) | 3(3) | ||
| Use soft tissue for drying | Yes | 72(72) | 89(89) | X2 = 9.21 (p = 0.00) |
| No | 28(28) | 11(11) | ||
| Use bath salts | Yes | 14(14) | 3(3) | X2 = 7.78 (p = 0.00) |
| No | 86(86) | 97(97) | ||
| Using cotton under wear | Yes | 82(82) | 89(89) | X2 = 1.98(p = 0.16) |
| No | 18(18) | 11(11) | ||
| Avoid tight clothes | Yes | 40(40) | 79(79) | X2 = 31.56 (p = 0.00) |
| No | 60(60) | 21(21) | ||
| Avoid fragrant soap for vaginal area | Yes | 48(48) | 91(91) | X2 = 43.61 (p = 0.00) |
| No | 52(52) | 9(9) | ||
| Avoid scent tissue for vaginal area | Yes | 70(70) | 98(98) | X2 = 29.17 (p = 0.00) |
| No | 30(30) | 2(2) | ||
| Void before going to bed | Yes | 92(92) | 91(91) | X2 = 0.06 (p = 0.80) |
| No | 8(8) | 9(9) | ||
| Eat food rich in vitamin C | Yes | 65(65) | 74(74) | X2 = 1.91 (p = 0.17) |
| No | 35(35) | 26(26) | ||
| Eat cranberry products | Yes | 7(7) | 10(10) | X2 = 0.58 (p = 0.45) |
| No | 93(93) | 90(90) | ||
Table 4.
Comparisons between the UTI group (N = 100) and the non-UTI groups (N = 100) related to hygiene and sexual practices
| UTI group | Non –UTI group | ||
|---|---|---|---|
| Number of times of bathing | Mean = 2.98 (SD = 1.45) | Mean = 5.13 (SD = 1.57) | t = -0.36 (p = 0.72) |
| Number of times of change under wear | Mean = 8.86 (SD = 4.4) | Mean = 10.43 (SD = 4.76) |
t = -2.69 (p = 0.01) |
| Number of times of urination | Mean = 6.51 (SD = 3.26) | Mean = 6.04 (SD = 1.70) |
t = 1.28 (p = 0.20) |
| Number of cups of water | Mean = 6.22 (SD = 1.92) | Mean = 8.07 (SD = 2.11) | t = -6.47 (p = 0.00) |
| Number of intercourse per week | Mean = 2.98 (SD = 1.45) | Mean = 2.02 (SD = 0.85) |
t = 5.69 (p = 0.00) |
Discussion
A total of 200 pregnant Jordanian women participated in the study that examined the occurrence of UTIs and its association with their sexual and hygiene practices: 100 and 100 in the UTI and non-UTI groups, respectively. The occurrence of UTI among pregnant women who attended the four maternity health centers in Zarqa city, central Jordan, was 21.5%, regardless of age, parity, or gestational age. This is similar to that reported by a Jordanian population and a family survey conducted in 2012 [17]. Research from Asian and Middle Eastern countries has shown a varied prevalence of UTI, with a rate of 2.3% in Israel and 35% in India. In our study, the researchers found that less than half of the participating women had a high school education and less than half of the women’s husbands had a high school education. These findings are congruent with the current Jordanian statistics that nearly half of Jordanian women completed secondary education (42%), whereas Jordanian men who completed secondary education were slightly higher (46%). Therefore, we concluded that this is a representative sample of the Jordanian population.
To the best of our knowledge, this is the first study to examine the risk factors of UTI among pregnant Jordanian women. We found a significant association between the occurrence of UTI and the educational level of the women’s husbands. With any decrease in the level of husband’s education, the occurrence of UTI among women was higher. Previous literature has discussed that if patients have a low educational level, they have problems understanding and accommodating information and adhering to any health advice [2]. However, this is in contrast to a report from Egypt, where no association was found between husbands’ education and the occurrence of UTI in pregnant women [27]. This variation in the association between the occurrence of UTI and husbands’ educational level may be due to variations in research methodology and sample size. Shaheen et al. used a case-control nested cross-sectional design and did not clearly explain their findings. In addition, a match between the case and control groups has not yet been clearly defined. In addition, they calculated the sample size based on the number of pregnant women who attended the center six months prior to the study and used the prevalence of UTI from the literature, and the sample size was calculated using G power. Sheehan et al. categorized husbands’ education into three levels (basic education, diploma, and high education), whereas in our study, it was categorized into five levels (illiterate, preparatory, secondary, high school, bachelor’s degree or higher).
The authors found a significant association between the history of UTI in previous pregnancies and the occurrence of UTI in the current pregnancy. The UTI occurrence was higher in patients with a history of UTI. It is possible that the women did not complete their antibiotic course or did not test their urine after one week of treatment completion. Previous studies have suggested that this association could be due to the ability of bacteria to colonize and replicate in the bladder at any time of vulnerability and low immunity, such as during pregnancy [28]. In addition, UTIs may be caused by a remnant of an antibiotic-resistant organism that occurred from a previous UTI attack. This result is congruent with the results of studies in different cultures (Pakistan, Bangladesh, Ethiopia, India, Egypt, and the Netherlands), which revealed a significant association between the occurrence of UTI and a history of UTI in previous pregnancies [27, 29].
A significant association was found between the pregnancy trimester and UTI occurrence. Our study found a higher occurrence of UTI in the second trimester, with 51% of the UTI group (51%) in the second trimester and 47% in the third trimester. This association may be due to urethral dilatation from the progesterone effect, which starts at six weeks and reaches a maximum at 22–24 weeks of pregnancy, resulting in urinary stasis and an increased risk of infection [30]. Our results were contrary to those reported in Bangladesh, India, and Ghana, where a significant association was found between the occurrence of UTI and women in the third and first trimesters [31, 32]. This variation could be due to differences in sample sizes and methodologies between these studies and our study. For example, Parveen et al.’s study (Bangladesh) was a cross-sectional study of 250 pregnant women, but they did not conduct any power analysis. Ranjan et al., in their study of 120 pregnant women in India, found a high occurrence of UTI in the third trimester, but they did not describe details about the study design, sampling method, power analysis, and characteristics of each group [31]. They attributed the increased occurrence of UTI during the third trimester to increased mechanical obstruction as a result of gravid uterus and pressure on the ureters, causing urine stasis [14, 33]. Laari et al. conducted a cross-sectional study in Ghana with 250 pregnant women who reviewed laboratory records of urinalysis results. They used the Taro Yamane formula to calculate sample size. They found a higher occurrence of UTI in the first trimester and attributed this to increased hormone production, rapid changes that occur during this trimester, and unpleasant pregnancy symptoms [34].
Regarding sexual practices, the current study revealed that there was a significant association between certain sexual behaviors and the occurrence of UTI among pregnant women, It was found that not voiding before intercourse, not voiding after intercourse, not washing the genitals before intercourse by the woman and her husband, and not taking a bath directly after intercourse were factors associated with the increase occurrence of UTI. This is because voiding and washing genitals may flush the bacteria that may cause a UTI. In addition, this study found that the use of vaginal creams, vaginal sprays, and vaginal fresheners before intercourse increased the occurrence of UTI in pregnant women. This may be because these chemicals provide a good medium for the multiplication of organisms. These results are congruent with those of previous studies that found a significant association between the occurrence of UTI and sexual practice among pregnant women. For example, not washing genitals before intercourse for women and their partners may increase the occurrence of UTI among pregnant women [30].
Our study showed a significant association between UTI occurrence in pregnant women and the number of intercourses per week; with an increased number of intercourses per week, the occurrence of UTI increased. In our sample, more than half of the women in the UTI group had intercourse three or more times per week, whereas a quarter of the women in the non-UTI group had intercourse three or more times per week. This association may be due to the anatomical relationship of female’s vagina and the urethra that makes it vulnerable to trauma during sexual intercourse [35, 36]. Moreover, intercourse may increase contamination of the urethra by E. coli and facilitate the entry of microorganisms into the urinary system, thereby increasing the occurrence of infection [33]. Similar results were reported in Egyptian, Pakistani, Bangladeshi, and Ethiopian studies indicating an association between sexual activity and the occurrence of UTI and they found that the occurrence of UTI increased as the number of times of intercourse increased [2]. Our study also found a strong association between the number of intercourses per week and number of baths per week. According to Islam, after each intercourse, both men and women should take a bath; thus, by increasing the number of intercourses, the number of times a person baths increases.
Our results showed a significant association between the number of times an individual changes underwear and UTI occurrence. The results showed that less than four women in the UTI group changed their underwear twice daily, whereas a quarter of the women in the non-UTI group changed their underwear twice daily. In addition, the results showed a significant association between the number of cups of water consumed per day and the UTI occurrence. A quarter of the pregnant women in the UTI group consumed two liters or more of water, whereas more than half of the pregnant women in the non-UTI group consumed two liters or more. One can infer that a decrease in the frequency of underwear and daily fluid intake may increase the occurrence of UTI among pregnant women. These results are supported by two Egyptian studies and one Iranian study that found a significant association between UTI and the frequency of change in underwear per day and daily fluid intake [2]. However, this is contrary to a recent Egyptian study that found that less frequent changes in underwear and low daily fluid intake were not significantly associated with UTIs among pregnant women. This variation may be related to their sampling technique and sample size; the researchers used purposive sampling to recruit 340 pregnant women, whereas our study used consecutive sampling to recruit 200 pregnant women [37].
Our study found a significant association between washing or drying genitals after voiding and the occurrence of UTI, which may be because the moist area is considered a good medium for the multiplication of some microorganisms that cause UTIs. These results are congruent with studies in Iran and Egypt, which found that non-drying of genitals after voiding increased the occurrence of UTI among pregnant women [27, 30].
The authors found a significant association between the occurrence of UTI and washing hands before and after urination. Washing hands before and after urination decreased the occurrence of UTI because washing hands can minimize the bacteria that may move from both hands to genitals. Our results are congruent with those of Mohamed et al. [38] who reported similar findings in their study on Egyptian women.
Our study showed a significant association between the occurrence of UTI and the use of non-soft tissues to dry genitals. Soft tissues are disposable and can reduce the transmission of microorganisms. Use of bath salts, wearing tight clothes, use of fragrant soaps in the perineal area, and use of scented tissue were found to be associated with an increased occurrence of UTI, as these practices may provide an environment suitable for the multiplication of microorganisms. There is a lack of research examining these variables and their association with UTIs in pregnant women; hence, comparisons are not feasible.
Implications for Healthcare Personnel
The authors recommend that policymakers support the implementation of evidence-based practice for managing UTIs, identifying the following: risk factors for UTIs during pregnancy, increased community awareness about UTIs among pregnant women [39], and screening and health education for preventive measures of UTIs. In practice, we recommend that health professionals educate the public, particularly pregnant women. Furthermore, they should be prepared and supported to plan and implement various health education programs systematically, based on the needs of the target audience. Further research is needed to build on the current study with a larger sample size and diverse samples of pregnant women from different geographical regions across Jordan, including private health centers. Future research should explore the reasons and barriers faced by health professionals in providing health education to women during pregnancy. Research can also examine the general hygiene practices of girls and boys of reproductive ages. Research should also focus on the effects of UTIs on maternal and infant health outcomes.
Limitations
This study had several limitations. First, this study was limited to only four governmental maternity health centers in central Jordan, so the results of this study cannot be generalized to all Jordanian women because other regions in Jordan and private and military centers or maternity clinics were not included. Broader sampling: Including a more diverse sample of pregnant women from other regions of Jordan, as well as those attending private or military health centers, could increase the generalizability of the findings.
Second, some pregnant women did not complete the questionnaire in its entirety and described these topics as private. Third, research on the association between hygiene and sexual practices in pregnant women with UTIs is lacking. The self-reporting method, especially in relation to private matters such as sexual behavior, could affect the reliability of the findings. Finally, the religious practices and personal habits of each culture vary; therefore, this cannot be compared with other cultures.
Conclusion
A total of 200 Jordanian pregnant women participated in the study, which examined the association between hygiene, sexual practices, and the amount of sexual intercourse with UTI during pregnancy. The study concludes that improving hygiene and sexual practices could reduce UTI occurrence. The occurrence of UTIs has increased among pregnant women with improper hygiene, sexual practices, and sexual intercourse. Therefore, there is a need to educate pregnant women on preventive behaviors regarding sexual and hygiene practices.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Acknowledgements
Not applicable.
Author contributions
Reem Hatamleh, Abeer Al-Trad, Sawsan Abuhammad, Mohammed Aljabari, Rachel Joseph was participated in writing and analyzing data. All the participants were participated in all steps of this study.
Funding
No funding was received for this study.
Data availability
Data will be available upon reasonable request.
Declarations
Ethical approval
This study received from Jordan University of Science and Technology and this with “in accordance with the Declaration of Helsinki.
Consent to participate
All participants sign consent to participate in the study.
Consent to publish
All participants sign consent to publish this study.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Data Availability Statement
Data will be available upon reasonable request.