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. 2025 Jan 30;25:90. doi: 10.1186/s12884-025-07182-2

Global seroprevalence of Toxoplasma gondii in pregnant women: a systematic review and meta-analysis

Nader Salari 1, Avijeh Rahimi 2, Hosna Zarei 2, Amir Abdolmaleki 3, Shabnam Rasoulpoor 4, Shamarina Shohaimi 5, Masoud Mohammadi 6,✉
PMCID: PMC11780849  PMID: 39885489

Abstract

Background

Toxoplasmosis in pregnancy is associated with serious and irreversible maternal and fetal detrimental consequences. Also, different seroprevalence of Toxoplasma gondii in pregnancy is reported in many countries. The present systematic review and meta-analysis study aimed to determine the global seroprevalence of Toxoplasma gondii in pregnant women.

Methods

This study was conducted based on the PRISMA 2020 criteria. Initial searching was conducted using MeSH (Medical Subject Headings)-based keywords with no time limitation (by August 1, 2024). Collected papers were transferred to Citation Management Software (EndNote). Duplicate studies were merged and primary and secondary screenings were applied based on the inclusion/exclusion criteria. Validation was considered to find high-quality assessments. Finally, eligible extractable papers were enrolled for data collection. Data was analyzed using Comprehensive Meta-Analysis software (v.2) The random effects model was used in case of I2 index above 50%.In order to investigate the factors affecting the heterogeneity of studies, meta-regression tests were used to examine factors such as sample size and year of study.

Results

One hundred thirty-eight eligible studies with a total sample size of 135,098 pregnant women individuals were selected for data extraction and analysis. The heterogeneity index was found high (I2:98.9) and the random effect model was used for analysis. The egger test revealed the absence of publication bias in collected studies (p:0.088). Thus, the global seroprevalence of Toxoplasma gondii in pregnant women was reported at 36.6% (95%CI:33.7–39.6). the highest prevalence reported based on meta-analysis was reported in South America with 52.8% (95% CI:46.6–59), while only 15 studies were reviewed in this continent, most of which were in Brazil. Therefore, after the continent, the highest prevalence reported was reported in Africa with 46.8% (95% CI:39.5–54.3). Also, the lowest prevalence reported based on meta-analysis was in North America with 19.7% (95% CI:8.4–39.6) and Europe with 24.6% (95% CI:17.8–32.9).

Conclusion

This study revealed a high level of seroprevalence of Toxoplasma gondii in pregnant women worldwide. This value mostly depends on the individual's age, lifestyle, and disease awareness regarding toxoplasmosis in pregnant women. Thus, public awareness, along with comprehensive health programs regarding the detrimental effects of toxoplasmosis in pregnant women, seems necessary for prevention or even early diagnosis of toxoplasmosis in pregnant women.

Keywords: Toxoplasma gondii, Pregnant women, Pregnancy, Meta-analysis

Background

Toxoplasmosis is an infectious-parasitic disease in humans and animals, caused by Toxoplasma gondii (TG) [1]. Felines are the only definitive hosts of this parasite and other vertebrates are considered intermediate hosts [2]. TG infection is transmitted through the presence of oocytes in water and food or soil (contaminated with cat feces), raw meat, organ transplantation, blood transfusion, and also placenta to fetus transfer during pregnancy [3–5].

Toxoplasmosis can affect healthy and immunocompromised individuals and can also be a life-threatening disease in immunosuppressed individuals [3–5]. The parasite is transmitted through raw meat containing TG cysts or water containing oocysts from cat feces. Although felines are the only definitive host, TG can infect and replicate in almost any nucleated vertebrate cell [4, 5]. The life cycle TG has an asexual phase that occurs in nucleated cells and a sexual phase in the digestive tract of cats. Fertilized gametes from sexual reproduction are produced in the cat's small intestine, and excreted oocysts can persist in the environment for up to 18 months. Both waterborne and foodborne transmission have been reported [5].

This pathology is demonstrated in three forms of acute, latent, or cutaneous. Although TG infection is often asymptomatic, the acute type of TG infection is resembling the Influenza symptoms such as fever, sore throat, weakness, inflamed lymph nodes, and muscle pain [6–9]. However, Toxoplasmosis is more severe in immunocompromised individuals with detrimental effects on the fetus [10].

Toxoplasmosis is often self-limiting in people with healthy immune systems, but it is a significant risk in immunocompromised individuals and pregnant women [4, 11]. Acute TP is associated with many complications for the fetus and pregnant mother [12, 13]. The risk of vertical transmission of TG from the placenta to the fetus increases from 25% in the first to 65% in the third trimesters followed by more severe complications such as miscarriage, premature birth, congenital-related Toxoplasmosis, retinopathy, neuropathy, homeopathy, hydrocephaly, microcephaly, and cerebral calcification. Thus, early diagnosis and treatment of acute Toxoplasmosis in pregnant women are necessary to reduce the severity of complications [3, 4, 12–20].

The TG seroprevalence of women in reproductive age or pregnant cases ranges from 1.4% to 85%, globally [18–20]. If this infection occurs during pregnancy and infects the pregnant mother, it can lead to congenital toxoplasmosis, which can be a threat to the health of the baby. Clinical manifestations of the infection can be observed later in infancy, childhood, or adolescence. Epidemiological studies of this disease show that from 1988 to 1994, the seroprevalence of infected women aged 15 to 44 years was 15%, while the prevalence decreased to 11% in 1999–2004, and in 2009–2010, the seroprevalence was reported to be 9.1% [19]. The highest TG seroprevalence is related to tropical regions, lower altitudes areas, developing (South America and Africa), and Middle East countries [4, 21]. However, high seroprevalence of TG is reported in many developed countries (like France) where people consume uncooked meat [21]. These differences indicate the alteration in reported cases of TG seroprevalence in different regions [21].

Serological screening is a valid procedure for diagnosis of acute (or chronic TG infection [16, 17]. After acute infection diagnosis in a pregnant mother, some antibiotics such as Spiramycin are prescribed with an effectiveness rate of > 60% to inhibit fetal congenital infection [7, 18, 19].

Assessment of the scientific dimensions of Toxoplasma gondii in pregnant women is important due to the development of preventive measures, early diagnosis, and treatment of acute Toxoplasmosis. Given that different reports of the prevalence of this disease in pregnant women around the world report different prevalences and high heterogeneity, Thus, this systematic review and meta-analysis study aimed to report the Global seroprevalence of Toxoplasma gondii in pregnant women.

Methods

This study was conducted based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement criteria (2020) [22]. The initial search was conducted on August 1, 2024, and updated on August 28, 2024 with no time limitation. The searching strategy was designed using the MeSH-based keywords of “Prevalence”, “Factors”, “Outcome”, “Toxoplasma gondii”, “Pregnant women”, and “Pregnancy” in major electronic databases, including PubMed, ScienceDirect, Scopus, Web of Sciences (WoS), Embase, and G.Scholar. References of included papers were also reviewed to cover the maximum number of eligible studies. All papers reporting the seroprevalence of Toxoplasma gondii in pregnant women were included in this study. Also, other variables (e.g., geographic location, diagnostic method, Age, Sample size) were collected for comprehensive assessment of data. The search strategy in the various databases examined is reported in Table 1.

Table 1.

Search strategy in various databases studied

Database Search Type Search strategy
PubMed Advanced search (((("prevalence"[Title/Abstract]) OR ("outcome"[Title/Abstract])) AND ("factors"[Title/Abstract])) AND ("toxoplasma gondii"[Title/Abstract])) AND ("pregnant women"[Title/Abstract])
ScienceDirect Advanced search Titke, abstract, keywords: (prevalence OR outcome) AND (factors) AND ("toxoplasma gondii") AND ("pregnant women")
Scopus basic search Titke, abstract, keywords: (prevalence OR outcome) AND (factors) AND ("toxoplasma gondii") AND ("pregnant women")
WOS basic search TS = (prevalence OR outcome) AND (factors) AND ("toxoplasma gondii") AND ("pregnant women" OR pregnancy)
Embase Advanced search prevalence:ab,ti AND 'toxoplasma gondii':ab,ti AND 'pregnant women':ab,ti
Google scholar Advanced search prevalence "pregnant women" OR pregnancy "toxoplasma gondii"
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Inclusion and exclusion criteria

Inclusion criteria: Studies that reported the prevalence of Toxoplasma gondii in pregnant women. Studies for which the full text was available. Studies that provided sufficient data (sample size, prevalence percentage). Studies whose text was in English. Analytical observational studies (cross-sectional). Studies conducted in countries around the world and on different continents all Toxoplasma gondii diagnostic methods.

Exclusion criteria were reviews studies, intervention studies, cohorts, case-controls, duplicate papers, non-English investigations, and all articles with insufficient or unextractable data.

Study selection and quality assessment

In this process, initial searching was applied and selected papers were transferred to the Citation Management Software (EndNote). Duplicate articles were detected and excluded. Following the primary screening, the “Title” and “Abstract” of all studies were evaluated and un-eligible studies were excluded. In the second screening, full-text of remaining papers was examined and the articles with insufficient or unextractable data were ignored. Selected papers were enrolled for quality control step. The Newcastle–Ottawa Scale (NOS), a quality assessment tool for observational studies, was used to assess the quality of the articles reviewed in this study. The NOS assigns a maximum of 9 points for the lowest risk of bias for three areas examined in the articles: four points for the selection of study groups, two points for the comparison of groups, and three points for the determination of exposure and outcomes for case–control and cohort studies, respectively. Finally, in this review, articles were considered as high quality (score ≥ 5) or low quality (score less than 5). Finally, 138 articles were reviewed and analyzed in this study.

Data extraction and meta-analysis

Data extraction was applied using a previously prepared checklist including Name of first author, Year of publication, Type of study, Study location, Sample size, Age range, Mean age, Number (or percentage of seroprevalence in 4 ranges of total, first, second, and third trimesters), and Number (or percentage) of IgG, IgM, and IgG/IgM antibodies (Table 2). After statistical extraction of data, Comprehensive Meta-Analysis software (CMA, v2) was hired for data analysis. Heterogeneity of the studies was assessed through the I2 index and the Egger test was used to check publication bias followed by the Funnel Plot diagram. The random effects model was used in case of I2 index above 50%.In order to investigate the factors affecting the heterogeneity of studies, meta-regression tests were used to examine factors such as sample size and year of study. Also, given the geographical scope of the study and the studies conducted in different countries around the world, subgroup analysis was also conducted based on continent.

Table 2.

Summary of the seroprevalence studies included in the review

Author Year Study Region Sample size Age Seroprevalence, n(%) SP trimesters, n (%) Total SM
Range Mean IgG IgM IgG/ IgM 1st 2nd 3rd
Abamecha et al [23] 2016 Cross sectional Ethiopia 232 - 23.65 191 (82.3) 0 (0) 7 (3) 56 (28.3) 100 (50.5) 42 (21.2) 198 (85.3) ELISA
Abdelbaset et al [6] 2020 Cross sectional Egypt 96 - 26.3 - - - 0 (0) 10 (35.7) 12 (23) 22 (22.9) LAT/ ELISA
Addo et al [1] 2023 Cross sectional Ghana 84 - 26.96 44 (52.38) 3 (3.57) - 11 (45.83) 17 (58.62) 19 (61.29) 47 (55.95) ELISA
Agmas et al [24] 2015 Cross sectional Ethiopia 263 18-44 29.56 - - - - - - 180 (68.4) LAT
Ahmadi et al [25] 2023 Retrospective crosssectional Iran 4225 15- 45 - 885 (20.8) 405 (9.5) 510 (12) - - - 1800 (42.6) ELISA
Ahmadpour et al [12] 2019 Cross sectional Iran 276 - 33.1 55 (19.92) 6 (2.17) 5 (1.81) - - - 66 (23.9) ELISA CLIA
Ahmed et al [26] 2014 Cross sectional Egypt 100 21-35 26,95 63 (63) 11 (11) 8 (8) - - - 82 (82) IHA
Akinbami et al [27] 2010 Cross sectional Nigeria 179 25 -30 - 73 (40.8) - - - - - 73 (40.8) ELISA
Akpınar et al [28] 2017 Retrospective crosssectional Turkey 3140 - - 344 (28.4) 34 (1.8) - 378 (12) 0 (0) 0 (0) 378 (12) Macro ELISA
Al Mohammad et al [29] 2010 Cross sectional SAR 554 18 -41 24.1 285 (51.4) 49 (8.8) 11 (2) - - - 345 (62.3) ELISA
Al-Adhroey et al [16] 2019 Cross sectional Yemen 420 16 -45 - 54 (12.9) 5 (1.2) 30 (7.1) 16 (18.8) 32 (21.3) 41 (22.2) 89 (21.2) ECL / ELISA
Al-Eryani et al [30] 2016 Cross sectional Yemen 593 15 -48 - 259 (43.7) 54 (9.1) 44 (7.4) _ _ _ 269 (45.4) ELISA
Al-Harthi et al [31] 2006 Cross sectional SAR 197 17 -45 - 58 (29.4) 11 (5.6) 4 (2) 64 (37.8) 9 (42.8) 0 (0) 73 (37) ELISA
Alghamdi et al [32] 2016 Cross sectional SAR 203 15 -45 32 66 (32.5) 13 (6.4) - - - - 79 (38.9) ELISA
Almogren [33] 2011 Retrospective crosssectional SAR 2176 - 25 825 (38) - - - - - 825 (38) IHA
Alvarado et al [34] 2006 Cross sectional Mexico 343 13 ≤ - 21 (6.1) 0 (0) - - - - 21 (6.1) ELISA
Amar et al [35] 2015 Cross sectional India 103 - - 26 (25.2) 2 (1.9) - 4 (21) 16 (27) 8 (32) 28 (27.18) ELISA
Andiappan et al [36] 2014 Prospective crosssectional Thailand 760 14 -47 29.5 167 (22) - 23 (3) 162 (26.1) 27 (20.9) 1 (10) 190 (25) ELISA
Andiappan et al [37] 2014 Prospective crosssectional Malaysia 219 - - 93 (42.4) - - 3 (60) 32 (40.5) 58 (43) 93 (42.4) ELISA
Andiappan et al [37] 2014 Prospective crosssectional Myanmar 215 - - 66 (30.7) - - 4 (66.7) 27 (28.4) 35 (30.7) 66 (30.7) ELISA
Antinarelli et al [38] 2021 Retrospective crosssectional Brazil 5895 - - 2591 (44.4) 5 (0.1) 110 (1.9) - - - 27.06 (45.9) CMIA
Asthana et al [39] 2006 Cross sectional Grenada 534 - - 304 (57) - - - - - 304 (57) ELISA
Atakorah et al [40] 2022 Cross sectional Ghana 150 18 - 40 27.83 72 (48) 17 (11.3) 11 (7.3) - - - 100 (66.66) ELISA
Awoke et al [41] 2015 Cross sectional Ethiopia 384 - 26.96 71 (18.5) - - 7 (17.9) 28 (20.6) 36 (17.2) 71 (18.5) LAT
Ayeah et al [4] 2022 Cross sectional Cameroon 300 16 - 41 28.05 218 (72.7) 4 (1.3) 18 (6) - - - 240 (80) ELISA
Aynioglu et al [42] 2015 Retrospective crosssectional Turkey 910 17 - 46 29 13 400 (43.9) 23 (2.5) - - - - 423 (46.48) CLIA
Baghel et al [43] 2020 Cross sectional India 200 35 ≤ - 11 (5.5) 0 (0) - - - - 11 (5.5) ELISA
Bamba et al [5] 2017 Cross sectional Burkina Faso 316 - 26.9 98 (31.1) - - - - - 98 (31.1) ELISA/ ELFA
Barbosa et al [44] 2009 Cross sectional Brazil 190 13 - 45 - 126 (66.3) 1 (0.52) - 16 (12.6) 53 (41.7) 58 (45.7) 127 (66.8) ELISA
Bashour et al [13] 2024 Cross sectional Iran 340 16 - 46 29.13 101 (29.7) - 2 (0.6) - - - 103 (30.3) ELISA/ PCR
Barzgar et al [2] 2024 Cross sectional Iran 1200 18 - 42 - 381 (31.7) 41 (3.4) - - - - 422 (35.1) ELISA
Bassiony et al [45] 2016 Cross sectional Egypt 382 17 - 44 26.71 219 (57.33) 43 (11.3) 41 (10.7) 77 (58.8) 98 (55) 46 (63) 221 (57.9) ELISA
Bjerke et al [46] 2011 Cross sectional Pakistani immigrants in Norway 206 18 - 44 27.3 36 (17.4) - - - - - 36 (17.4) EIA
Chandrasena et al [47] 2016 Cross sectional Sri Linka 293 - 27 36 (12.3) 0 - - - - 36 (12.3) RDT
Chemoh et al [9] 2019 Cross sectional Malaysia 219 20–40< - 67 (30.6) 5 (2.3) 4 (1.8) 4 (23.5) 38 (33.3) 34 (38.6) 76 (34.7) ELISA
Costa et al [48] 2018 Cross sectional Brazil 463 13 - 44 24 335 (72.3) 17 (3.7) - - - - 352 (76.02) ELISA
Cvetković et al [49] 2010 Retrospective Crosssectional Macedonia 235 15 - 45 - 48 (20.4) - - - - - 48 (20.4) ELISA
da Rocha et al [50] 2015 Cross sectional Brazil 338 - - 240 (71) 0 0 (0) - - - 240 (71) MEIA
Daka et al [11] 2024 Cross sectional Zambia 401 24 - 30 27 17 (4.2) 3 (0.7) 1 (0.2) 0 (0) 11 (57.9) 8 (42.1) 19 (4.7) ELISA
De Paschale et al [51] 2008 Cross sectional Italy 3426 15 - 44 - 737 (21.5) 42 (1.2) - - - - 779 (22.7) ELISA
De Paschale et al [52] 2014 Cross sectional Benin 283 15 - 41 26.2 737 (21.5) 42 (1.2) - - - - 86 (30) ELISA
De Quadros et al [53] 2015 Cross sectional Brazil 148 14 - 41 - 24 (16) 1 (0.6) - - - - 25 (16.9) -
Deka et al [54] 2022 Cross sectional India 165 - 27.6 63 (38.2) 22 (13.3) 18 (10.9) - - - 68 (41.2) ELISA
Duarte et al [55] 2020 Cross sectional Brazil 201 - 27.5 54 (26.8) 0 - - - - 54 (26.8) IFA
Dwinata et al [56] 2017 Cross sectional Indonesia 330 17 - 40 27 36 (10.9) - - - - - 36 (10.9) ELISA
Edrees et al [18] 2020 Cross sectional Iraq 150 - 29.9 40 (26.7) 0 - 9 (16.9) 19 (28.3) 12 (40) 40 (26.7) ELISA
El Deeb et al [57] 2012 Cross sectional Egypt 323 19 - 39 - 218 (67.5) 9 (2.8) 9 (2.8) 80 (69.6) 46 (63.9) 92 (67.6) 218 (67.5) ELFA/ VIDAS
Elsheikha [58] 2008 Cross sectional Egypt 350 - 25.2 211 (60.3) - - - - - 211 (60.3) ELISA
Endris et al [59] 2014 Cross sectional Ethiopia 385 20 - 30 - 341 (88.6) - - 14 (70) 228 (89.8) 99 (89.2) 341 (88.6) LAT
Eshratkhah et al [60] 2018 Cross sectional Iran 620 14 - 47 - 114 (18.4) - 3 (0.5) 117 (18.9) 0 0 117 (18.9) ELISA
Fenta [61] 2019 Cross sectional Ethiopia 494 15 - 42 26.47 370 (74.9) 19 (3.8) 15 (3.1) 79 (19.6) 140 (34.7) 185 (45.8) 404 (81.8) ELISA
Findal et al [62] 2015 Cross sectional Norway 1922 15 - 46 - 179 (9.3) - - - - - 179 (9.3) ELISA
Flores et al [63] 2021 Cross sectional Panama 2326 - - 997 (42.9) 5 (0.21) 31 (1.33) - - - 1033 (44.4) avidity test
Fonseca et al [64] 2012 Cross sectional BrazilL 2136 20 - 49 - 1057 (49.5) 77 (3.6) - - - - 1134 (53) -
Frimpong et al [65] 2017 Cross sectional Zambia 411 15 - 49 - 24 (5.87) 0 - 3 (3.57) 11 (8.21) 10 (5.18) 24 (5.87) RDT
Garedaghi et al [66] 2017 Cross sectional Iran 200 - - 79 (39.5) 5 (2.5) 2 (1) 40 (43.4) 11 (44) 33 (39.7) 82 (41) ELISA
Gelaye et al [67] 2015 Cross sectional Ethiopia 288 18 - 42 28.41 - - - 14 (77.8) 52 (88.1) 180 (85.3) 246 (85.4) LAT
Gheshlaghi et al [15] 2022 Cross sectional Iran 740 14 - 48 28.1 157 (21.2) 2 (0.27) - - - - 159 (21.5) ELISA
Hajsoleimani et al [68] 2012 Cross sectional Iran 500 - - 186 (37.2) 7 (1.4) - 74 (43.5) 52 (35.9) 63 (34) 189 (37.8) ELISA
Hansu et al [69] 2021 Retrospective crosssectional Turkey 29424 15 -45 - 6035 (20.5) 502 (1.7) 255 (0.86) 6282 (21.34) 0 0 6282 (21.34) -
Hariri et al [70] 2023 Cross sectional Iran 244 16 -43 23.06 54 (22.1) 0 (0) - - - - 54 (22.1) ELISA
Hassanain et al [71] 2018 Cross sectional Egypt 388 18 -44 27 - - - 0 (0) 40 (33.1) 39 (35.8) 79 (20.4) ELISA
Hosseini et al [72] 2023 Cross sectional Iran 100 - - 68 (68) 1 (1) - - - 69 (69) ELISA
Hung et al [73] 2007 Cross sectional Sao Tome and Principe 499 - 25.4 - - - - - 375 (75.2) LAT
Hung et al [74] 2015 Cross sectional Taiwan 104 20 -42 30.91 7 (6.7) 0 1 (1) - - - 8 (7.7) ELISA
Ijaz et al [75] 2020 Prospective Crosssectional Pakistan 418 - 33 140 (33.5) 28 (6.7) 12 (2.9) - - - 180 (43) ELISA
Iqbal et al [76] 2007 Cross sectional Kuwait 224 19 -41 27 119 (53.1) 31 (13.8) - 150 (66.96) 0 (0) 0 (0) 150 (66.96) ELFA/ VIDAS
Jahantigh et al [77] 2020 Cross sectional Iran 90 - - 13 (14) 0 (0) - 6 (15) 7 (14) 0 (0) 13 (14) ELISA
Jiang et al [78] 2018 Cross sectional China 313 - - 43 (13.74) 4 (1.28) 4 (1.28) - - - 51 (16.29) ELISA
Jula et al [79] 2018 Prospective cross sectional Ethiopia 401 - 23.1 - - - 19 (25.3) 42 (26.6) 35 (20.8) 96 (23.9) EIA
Karabulut et al [80] 2011 Cross sectional Turkey 1102 18-40 29.8 408 (37) 15 (1.4) 97 (8.8) 520 (47.2) 0 (0) O (0) 520 (47.2) Vitros ECiQ
Kassie et al [81] 2024 Cross sectional Ethiopia 340 18-44 - 132 (38.8) - - - - - 132 (38.8) ELISA
Kaur et al [82] 1999 Prospective cross sectional India 120 16-36< - - 14 (11.6) - - - - 14 (11.6) -
Khademi et al [83] 2019 Cross sectional Iran 360 14-55 27 100 (27.8) - 3 (0.83) - - - 103 (28.6) ELISA
Khames et al [84] 2020 Cross sectional Algeria 1012 - - 187 (18.5) 16 (1.6) 49 (4.8) - - - 252 (25) ELISA
Kledmanee et al [85] 2019 Cross sectional Thailand 105 15-49 - - - - - - - 33 (31.4) ELISA
Linguissi et al [86] 2012 Retrospective crosssectional Burkina Faso 182 18≤ - 37 (20.3) 7 (3.8) - 44 (24.17) 0 (0) 0 (0) 44 (24.17) ELISA
Liu et al [87] 2009 Cross sectional China 235 21 -38 - 25 (10.6) 0 (0) - - - - 25 (10.6) ELISA
Lobo et al [20] 2017 Cross sectional Portugal 155 15 -44 - 17 (10.95) 0 (0) 17 (10.95) - - - 34 (21.9) DAT/ ISAGA
Lobo et al [20] 2017 Cross sectional Angola 300 15 - 44 - 71 (23.7) 6 (2) 5 (1.7) 18 (26.9) 41 (27.5) 23 (27.4) 82 (27.3) DAT/ ISAGA
Lopes-Mori et al [88] 2013 Cross sectional Brazil 2226 - 25 1122 (50.4) - - - - 93 (55) 1151 (51.7) ELISA
Mahdy et al [89] 2017 Cross sectional Yemen 359 22 - 30 26 154 (42.89) 7 (1.9) - - - 55 (46.2) 166 (46.2) ELISA
Majid et al [90] 2016 Cross sectional Pakistan 733 15 - 40 - 135 (18.41) - - 21 (7.17) 43 (20.19) 71 (31.28) 135 (18.41) IFA
Marković et al [91] 2023 Cross sectional Serbia 300 15≤ - - 0 (0) - 13 (34.2) 6 (15.8) 19 (50) 38 (12.7) VIDAS
Mohamed et al [92] 2016 Cross sectional SAR 326 16 - 40 30.19 69 (21.2) 4 (1.2) - 18 (25.7) 20 (23.5) 35 (20.8) 73 (22.4) ELISA
Mosawi et al [93] 2019 Cross sectional Afghanistan 431 - - - - - - - - 207 (48.03) CLIA
Motoi et al [94] 2020 Cross sectional Romania 6889 18–36< - 2746 (39.86) - - - - - 2746 (39.86) CLIA
Mulugeta et al [10] 2020 Cross sectional Ethiopia 233 18 - 42 26.11 - - - 27 (79.4) 59 (64.1) 72 (67.3) 158 (67.8) LAT
Murad et al [95] 2023 Cross sectional Iraq 180 15 - 50 - 110 (61.1) - - 33 (76.7) 27 (55.1) 50 (56.8) 110 (61.1) ELISA
Murad et al [96] 2023 Cross sectional Iraq 400 15 - 50 - 205 (51.3) - - - - - 205 (51.3) ELISA
Mwambe et al [97] 2013 Cross sectional Tanzania 350 15 - 44 - - - - 4 (26.7) 50 (33.3) 55 (29.7) 108 (30.9) ELISA
Nasir et al [98] 2015 Cross sectional Nigeria 360 18 - 40 30 144 (40) 32 (8.9) 6 (1.7) 38 (-) 44 (-) 94 (-) 176 (48.88) ELISA
Ndumbe et al [99] 1992 Cross sectional Cameroon 192 - - 148 (77.1) - - - - - 148 (77.1) EIA
Nijem et al [100] 2009 Cross sectional Palestine 204 16 - 43 26.4 57 (27.9) 36 (17.6) - 93 (45.5) 0 (0) 0 (0) 93 (45.5) ELISA
Nissapatorn et al [101] 2003 Cross sectional Malaysia 200 18 - 43 29.6 78 (39) 8 (4) 12 (6) 2 (33.3) 19 (45.2) 77 (49) 98 (49) ELISA
Njunda et al [102] 2011 Cross sectional Cameroon 110 18 - 41 - 69 (62.7) 0 (0) 3 (2.7) 30 (75) 40 (60.6) 2 (50) 72 (65.4) ELISA
Njunda et al [103] 2011 Cross sectional Cameroon 110 20 - 44 - 77 (70) 3 (2.7) - 14 (87.5) 39 (66.1) 24 (70) 77 (70) ELISA
Nowakowska et al [104] 2006 Cross sectional Poland 4916 19 - 46 26.7 2030 (41.3) - - - - - 2030 (41.3) IDAT/ ELISA
Ocak et al [105] 2007 Cross sectional Turkey 1652 16 - 42 27.2 860 (52.1) 9 (0.54) - - - - 869 (52.6) ELISA
Olariu et al [106] 2020 Cross sectional Romania 208 Dec-41 27.1 - - - - - - 116 (55.8) Vitros ECIQ
Oliveira et al [107] 2019 Cross sectional Brazil 196 - - 133 (67.9) 3 (1.5) - - - - 136 (69.3) CLIA
Ouermi et al [108] 2009 Cross sectional Burkina Faso 276 19 - 42 27.65 75 (27.2) 13 (4.7) - - - - 88 (31.9) ELISA
Oyinloye et al [109] 2014 Cross sectional Nigeria 90 15–35< - 20 (22.2) - - 2 (18.1) 8 (29.6) 10 (19.4) 20 (22.2) ELISA
Pereira et al [110] 2024 Cross sectional Brazil 280 15 - 43 26 69 (24.6) - - 35 (27.13) 9 (16) 25 (26.3) 69 (24.6) CLIA
Qamer et al [111] 2020 Cross sectional SAR 306 16 - 45 29.9 99 (32.4) 3 (1) - - - - 101 (33) ECL
Rocha et al [112] 2015 Cross sectional Brazil 338 - - 240 (71) 0 (0) - - - - 240 (71) MEIA
Rosso et al [113] 2008 Cross sectional Colombia 955 14 - 40 25.1 437 (45.8) 27 (2.8) - - - - 464 (48.5) MEIA
Sakikawa et al [114] 2012 Cross sectional Japan 4466 16 - 46 27.4 - - - - - - 459 (10.3) LAa titer
Salih [115] 2010 Cross sectional Iraq 260 15 - 44 - 80 (30.76) 31 (11.92) - - - - 111 (42.7) ELISA
Sandoval et al [116] 2020 Cross sectional Mexico 311 18 - 44 - 13 (4.2) 0 (0) - - - - 13 (4.2) ELISA
Santos et al [117] 2017 Cross sectional Brazil 200 - - 125 (62.5) - - - - - 125 (62.5) IFA
Sen et al [118] 2012 Cross sectional India 380 - - - 74 (19.4) - 74 (19.4) 0 (0) 0 (0) 74 (19.4) ELISA
Sharbatkhori et al [119] 2014 Cross sectional Iran 555 - - 221 (39.8) 19 (3.4) 8 (1.4) 97 (47.3) 76 (45.7) 67 (36.4) 232 (41.8) ELISA
Silva-Díaz et al [120] 2020 Cross sectional Peru 218 - 25.5 66 (30.3) 12 (5.5) - 20 34.4) 26 (38.8) 32 (34.4) 78 (35.8) ELISA
Singh et al [121] 2021 Cross sectional Ghana 400 - - 229 (57.3) 14 (3.5) 12 (3) 231 (57.8) 0 (0) 0 (0) 231 (57.8) ELISA
Sirin et al [122] 2017 Retrospective Cross sectional Turkey 7513 18 - 45 - 2427 (32.3) 138 (1.9) - - - - 2565 (34.1) CEIM
Sitoe et al [123] 2010 Cross sectional Mozambique 150 15 - 50 32 28 (18.7) 1 (3.6) - 29 (19.3) 0 (0) 0 (0) 29 (19.3) -
Sroka et al [124] 2010 Cross sectional Brazil 963 Dec-44 - 661 (68.6) 5 (0.5) - - - - 666 (69.1) MEIA
Tamer et al [125] 2009 Retrospecrive Cross sectional Turkey 1972 - 28.56 952 (48.3) 8 (0.4) 31 (1.6) 991 (50.2) 0 (0) 0 (0) 991 (50.2) ELISA
Teweldemedhin et al [126] 2019 Cross sectional Ethiopia 360 15 - 49 - 117 (32.5) - 11 (3.1) 41 (36) 42 (32.3) 45 (38.8) 128 (35.5) ELISA
Uysal et al [127] 2013 Retrospective crosssectional Turkey 4691 15 - 45 - 1871 (39.9) 0 (0) 48 (1.02) 1919 (41) 0 (0) 0 (0) 1919 (41) ELISAVIDAS
van Enter et al [128] 2017 Retrospective crosssectional Thailand 199 16 - 46 26 - - - - - - 63 (31.7) ELISA
Vueba et al [129] 2020 Cross sectional Angola 878 15 - 47 29.7 346 (39.4) 0 (0) 2 (0.2) 97 (35.2) 148 (39.1) 103 (45.7) 348 (39.6) ECL
Yasmeen et al [130] 2017 Cross sectional India 251 18 - 35 - 53 (21.1) - - - - - 53 (21.1) ELISA
Zemene et al [131] 2012 Cross sectional Ethiopia 201 17 - 35 23.64 163 (81.1) 2 (1) 3 (1.5) 23 (79.3) 86 (82.7) 59 86.8) 168 (83.6) ELISA
Adeniyi et al [7] 2023 Cross sectional Nigeria 320 14 - 50 - 76 (23.75) 35 (10.94) - - - - 111 (34.69) RDT
ALANAZI et al [3] 2017 Prospective Crosssectional Saudi Arabia 461 16 - 45 26.3 189 (40.9) 0 (0) - 8 (21.6) 77 (37.3) 104 (47.7) 189 (40.99) ELISA
Aleem et al [17] 2018 Cross sectional Pakistan 360 18 - 33 - - - - 71 (61.7) 59 (58.4) 40 (27.7) 170 (47.2) LAT
Ballah et al [8] 2017 Prospective Crosssectional Nigeria 400 15 - 49 - - - - 38 (21.3) 57 (33.5) 17 (32.7) 112 (28) ELISA
Cédric et al [22] 2022 Cross sectional Cameroon 117 14 - 40 - 27 (23.1) 1 (0) 2 (1.7) 3 (20) 27 (30) 0 (0) 28 (24) -
Dawet et al [14] 2022 Cross sectional Nigeria 356 15 - 49 - 105 (29.5) - - 25 (27.78) 55 (26.57) 25 (42.37) 105 (29.5) ELISA
Khan et al [21] 2018 Cross sectional Pakistan 150 20 – 50< - 1 (0.6) 1 (0.6) - - - - 2 (1.32) RDT
Lushina et al [132] 2023 Cross sectional Tanzania 383 - - 102 (26.6) 2 (0.52) - 25 (31.3) 40 (26) 39 (29.2) 104 (27.2) -
Murebwayire et al [133] 2017 Cross sectional Rwanda 384 18 - 45 27 37 (9.6) 15 (3.9) 5 (1.3) 8 (10) 26 (12.6) 13 13.4) 47 (12.2) ELISA
Nadia et al [134] 2023 Cross sectional Cameroon 242 16 - 46 - 152 (62.8) 28 (11.6) 20 (8.3) 79 (75.2) 77 (80.2) 24 (58.5) 200 (82.7) ELISA
Negero et al [135] 2017 Cross sectional Ethiopia 210 15 - 44 - - - - 20 (74) 62 (77.5) 77 (74.8) 159 (75.7) LAT
Paul et al [136] 2018 Cross sectional Tanzania 254 - 29.9 102 (40.2) 23 (9.1) 12 (4.7) - - - 113 (44.5) ELISA
Shah et al [137] 2017 Cross sectional Pakistan 100 17 - 36 - 7 (7) 12 (12) 7 (7) 2 (6.45) 3 (8.82) 7 (20) 12 (12) RDT
Song et al [138] 2005 Cross sectional Korea 5725 20 - 40 - - - - - - - 51 (0.88) ELISA/LAT
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Results

Following initial searching using valid databases and manual reviewing (Checking references of peer-reviewed articles), 1443 (PubMed (125), ScienceDirect (28), Scopus (308), Web of Sciences (WoS) (515), Embase (367), and Google Scholar (100) and 15 articles were selected in other resources, respectively (n:1458 in total). 898 duplicate articles were merged using EndNote software. During primary and secondary screenings, 560 and 411 studies were excluded, respectively and 11 low-quality articles were ignored. Finally, 138 eligible studies were included for data extraction (Fig. 1 and Table 2).

Fig. 1.

Fig. 1

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Flowchart of PRISMA criteria (2020) indicating the stages of article selection

Meta-analysis

In the review of 138 studies with a sample size of 135,098 prgnant women individuals, heterogeneity index was found high (I2:98.9); thus, random effect model was used for data analysis. The overall seroprevalence of Toxoplasma gondii in pregnant women was found 36.6% (95%CI:33.7–39.6) (Fig. 2). Also, Egger test showed no publication bias among the studies (p:0.088) (Fig. 3).

Fig. 2.

Fig. 2

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Forest plot of TP seroprevalence based on random effect model. TP: Toxoplasmosis in pregnant

Fig. 3.

Fig. 3

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Funnel plot representing distribution bias in selected eligible studies

Meta-regression analysis

Meta-regression analysis showed that following the increase in sample size (Fig. 4) and year of paper publication (Fig. 5), the seroprevalence of Toxoplasma gondii in pregnant women decreased significantly (p < 0.05).

Fig. 4.

Fig. 4

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Meta-regression represents the effect of sample size on the prevalence of Toxoplasma in pregnant women

Fig. 5.

Fig. 5

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Meta-regression represents the effect of the year of publication on the prevalence of Toxoplasma serum in pregnant women

Subgroup analysis

According to the results of Table 3, which reports the Global seroprevalence of Toxoplasma gondii in pregnant women by continent, the highest prevalence reported based on meta-analysis was reported in South America with 52.8% (95% CI:46.6–59), while only 15 studies were reviewed in this continent, most of which were in Brazil. Therefore, after the continent, the highest prevalence reported was reported in Africa with 46.8% (95% CI:39.5–54.3). Also, the lowest prevalence reported based on meta-analysis was in North America with 19.7% (95% CI:8.4–39.6) and Europe with 24.6% (95% CI:17.8–32.9) (Table 3).

Table 3.

Global seroprevalence of Toxoplasma gondii in pregnant women by continent

Continent N Sample size Heterogenicity (I2) Egger test Prevalence (95% CI)
Africa 47 14,579 98.4 0.345 46.8 (95% CI:39.5–54.3)
Asia 64 84,001 98.9 0.385 29.4 (95% CI:25.9–33.1)
Europe 9 18,257 99.1 0.150 24.6 (95% CI:17.8–32.9)
North America 3 3514 98.8 0.256 19.7 (95% CI:8.4–39.6)
South America 15 14,747 97.8 0.408 52.8 (95% CI:46.6–59)
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Discussion

This systematic review and meta-analysis study investigated the global seroprevalence of Toxoplasma gondii in pregnant women. In this regard, 138 eligible studies with the sample size of 135,098 prgnant women individuals were examined. The overall seroprevalence of Toxoplasma gondii in pregnant women was found 36.6%, the highest prevalence reported based on meta-analysis was reported in South America with 52.8%, while only 15 studies were reviewed in this continent, most of which were in Brazil. Therefore, after the continent, the highest prevalence reported was reported in Africa with 46.8% Also, the lowest prevalence reported based on meta-analysis was in North America with 19.7% and Europe with 24.6%.

According to the researches, Toxoplasmosis in pregnancy are mostly diagnosed in the third trimester of pregnancy [1, 4, 8, 13, 15]. This fact returns to the suppressive role of immune system in gestation, especially in third trimester [23].

However, the severity of fetal complications is higher in first months of pregnancy such as mental retardation, chorioretinitis, and blindness [3, 7, 13]. Thus, TG screening is strictly recommended for those exposed to the associated risk factors [3, 4]. The prevalence of TG infection depends on the presence of several risk factors such as living environment, education level, presence of cat in home, consumption of undercooked meat, and contact with contaminated soil. However, some other differences are associated with cultural beliefs and lifestyles [12, 17, 60, 71].

Most of the studies reported a considerable relationship between the prevalence of Toxoplasmosis and raw meat [2, 18, 31, 33, 61, 97, 134]. However, some studies reported no significant relationship in this regard [4, 23, 24, 67, 131]. These different reports also depend on the frequency of raw meat consumption and type of meat (pig, sheep) [23, 131]. According to studies, the educational status of women represents a considerable relationship with the seroprevalence of TG. Thus, a lower educational level is considered a risk factor for onset of TG in pregnant women [2, 4, 21, 24, 33, 85, 134].

Most studies reported a significant relationship between higher age and accelerated prevalence of Toxoplasmosis [4, 24, 26, 28, 31, 61, 85, 97, 131, 134]. For example, Mwambe et al. reported that the risk of TG infection in pregnant women increases by 7% in each year of the age [97]. According to studies, tropical and humid weather are important risk factors in increasing the prevalence of Toxoplasmosis in pregnant women [2, 8, 23]. In such areas, the growth and development of TG eggs are environmentally probable [2]. It should be noted that each of the above-mentioned risk factors alone has no considerable effect on Toxoplasmosis onset, however simultaneous presence of several risk factors could induce a higher rate of Toxoplasma gondii.

The most important measures are the use and benefit of primary and secondary prevention, that is, firstly, contact and disease development can be prevented and in case of contact, screening and diagnosis of the disease can be increased [139]. The primary prevention strategy includes providing educational materials on possible preventive measures that should be integrated into prenatal visits, classes, and programs [139]. Among the primary preventive measures, women should avoid sources of infection, not drink unfiltered water, and observe hand hygiene. Screening as a secondary prevention is essential for early identification of infected women. However, until screening programs are implemented, it can be said that primary prevention and the use of educational programs are much more effective in reducing the incidence [139].

Some important limitations were detected in this systematic review and meta-analysis, including non-uniformity of sample size or data and the use of different serological methods with unique sensitivity and characteristics. It is suggested that future studies in this field should consider population prevalence, as well as review interventional and diagnostic studies in this area and provide their results to researchers.

Conclusion

The overall seroprevalence of Toxoplasma gondii in pregnant women was high at 38.6% globally. Therefore, substantial efforts are needed to educate pregnant women and to implement policy measures globally. Therefore, increasing public awareness about Toxoplasma gondii and its associated risk factors is essential. In addition, rigorous health programs should be considered by health policymakers for the prevention and early detection of Toxoplasma gondii in pregnant women. In this context, screenings at specific times for pregnant women can be considered.

Acknowledgements

By Student Research Committee of Kermanshah University of Medical Sciences.

Abbreviations

TP

Toxoplasmosis in pregnancy

SM

Serological method

ELISA

Enzyme-linked Immunosorbent assay

LAT

Latex agglutination test

CLIA

Chemiluminescence immunoassay

ECL

Electrochemiluminescence

IHA

Indirect hemagglutination test

CMIA

Chemiluminescent microparticle immunoassay

ELFA

Enzyme-linked fluorescence assay

PCR

Polymerase chain reaction

RDT

Rapid diagnostic test

EIA

Enzyme-linked immunoassay

MEIA

Microparticle enzyme-linked immunoassay

IFA

Indirect immunofluorescence assay

VIDAS

Vitek immunodiagnostic system

ISAGA

Immunosorbent agglutination assay

CEIM

Chemiluminescent enzyme immunoassay method

Authors’ contributions

NS and AR and MM contributed to the design, MM statistical analysis, and participated in most of the study steps. MM and AR and HZ and SR prepared the manuscript. MM and HZ and SHSH and AA assisted in designing the study, and helped in the, interpretation of the study. All authors have read and approved the content of the manuscript.

Funding

Not applicable.

Data availability

Datasets are available through the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

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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Associated Data

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Data Availability Statement

Datasets are available through the corresponding author upon reasonable request.

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