Prevalence and Associated Risk Factors of Intestinal Parasitic Infections among Pregnant Women Attending Antenatal Care in Yifag Health Center, Northwest Ethiopia

Background A cross-sectional study was conducted from November 2019 to March 2020 to determine the prevalence and associated risk factors of intestinal parasitic infections (IPIs) among pregnant women attending antenatal care (ANC) at Yifag Health Center. Methods The data were collected by a questionnaire interview technique and collecting the stool samples from each pregnant woman. Wet-mount and formol-ether concentration techniques were applied to identify the IPIs. Data were analyzed using SPSS, version 25, and P-values < 0.05 were considered statistically significant. Results Out of the total 280 pregnant women who were selected using a simple random sampling technique, 277 participated in the questionnaire survey and gave stool samples (a response rate of 98.9%). The prevalence of IPIs among pregnant women was 53.4% (95% CI: 47.37, 59.42). Taenia species (18.1%) was the predominant parasite followed by Giardia lamblia (12.6%), Entamoeba histolytica/dispar (9.4%), hookworms (9%), Ascaris lumbricoides (4%), Schistosoma mansoni (3.2%), Hymenolepis nana (0.7%), Strongyloides stercoralis (0.4%), and Enterobius vermicularis (0.4%). Eating raw vegetables (AOR = 2.721; 95% CI: 1.266, 5.849; P=0.010) and poor personal hygiene (AOR = 4.015; 95% CI: 1.456, 11.07; P=0.007) were associated risk factors for G. lamblia, while eating raw meat (AOR = 2.477; 95% CI: 1.252, 4.902; P=0.009) for Taenia species infections. The prevalence of intestinal parasites was high and still a health burden to the pregnant women in the study area. We recommend avoiding eating raw meat, strengthening sanitation and hygiene programs, and routine deworming of pregnant mothers to reduce the burden of IPIs among pregnant women.


Introduction
Amebiasis, ascariasis, hookworm, and trichuriasis are among the top ten common intestinal parasitic infections (IPIs) [1]. IPIs caused by pathogenic helminth and protozoan species are endemic throughout the world, peculiarly in developing countries [2,3]. About one-fourth of the world's population lives with intestinal parasites [4].
e aim of this study, therefore, was to determine the prevalence and associated risk factors of IPIs among pregnant women attending ANC at Yifag Health Center. e findings from this study would provide information about the status of IPIs and their associated risk factors among pregnant women in the Amhara region, serve as a springboard for Libokemkem District health officers and regional health officers, and will provide baseline information for further studies.

Study Area, Design, and Population.
e location of Yifag Health Center is in Libokemkem District, South Gondar Zone, North West Ethiopia, at 12°5'0" latitude north and 37°44'0" longitude east. Its elevation ranges from 1829 to 1868 meters above sea level. It lies 77 km east of Bahir Dar, the capital city of the Amhara region, and 645 km northwest of Addis Ababa, the capital city of Ethiopia. It has a mean rainfall of 1330 ml and a mean temperature ranging from 22 to 30°C.
ere are five kebeles (lowest administrative units) whose residents are getting service from the health center. ese kebeles harbor a total population of 198,374 (97,423 females, 100,951 males) [11]. Most of the residents of the study area are farmers who use mixed agriculture. e main cultivated crops are rice, maize, chickpea, oats (rye), and little irrigation practice of onion and garlic. Dug well and pipe waters are the sources of drinking water in the study area. But most people use river water for hygienic purposes. e sanitary facilities in the study area are open latrine systems. ere are six health posts and one health center in the study area.
A health center-based cross-sectional study was conducted from 30 November 2019 to 07 March 2020. All the women visiting Yifag Health Center during the study period were the source population, while all the pregnant women were the study population.

Inclusion and Exclusion Criteria.
e study included all pregnant women who were willing to give stool, sign informed consent, and did not take antiparasitic drugs for the last three weeks before screening.

Sample Size Determination and Sampling Technique.
e sample size calculation used the single population proportion formula considering 95% CI and P � 0.21 [12] and adding 10% assumption of nonresponse rate as follows: where n is the sample size, z α/2 � 1.96 for the standard scale of 95% level of confidence, and d is the marginal error, which is 0.05.

Collection of Stool
Samples. e respondents were given clear instructions and provided with clean labeled collection cups along with applicator sticks. Each mother delivered about four grams of a fresh stool sample. e data collector registered the date of sampling, the name of each participant, and the age of each participant during data collection. e WHO guideline [13] was employed to process and examine a portion of each of the stool samples using direct wet-mount and formol-ether concentration techniques in the YHC laboratory class for parasitological examination.

Questionnaire Survey.
e researchers developed a structured questionnaire first in the English language. e questionnaire incorporated issues about the sociodemography, water source, personal hygiene, latrine availability, residence, attitudes on IPIs, basic knowledge on common signs and symptoms of IPIs, pregnancy month, and interpregnancy of the respondents. en, it was translated into the local language (Amharic) for interview. Before the interview, the questionnaires were pretested among thirty mothers. en, we made the necessary adjustments based on the feedback. e data collectors interviewed the respondents during stool collection. We translated the responses back into English for data analysis.

Direct Microscopy (Wet Mount) Procedure.
In the wet mount, a fresh stool sample of each participant (about 2 mg) was placed on a glass slide with a wooden applicator, emulsified with a drop of physiological saline (0.85%) for diarrheic and semisolid samples. For formed stools, iodine was used. en, covered with cover slide and examined for the presence of motile intestinal parasites and trophozoites under a microscope using first X10 objectives and then X40 objectives [14].

Formol-Ether Concentration Technique.
A portion of each stool sample was used for the detection of parasitic ova and protozoan cysts using the formol-ether concentration technique. About 2 grams of each stool sample was first emulsified with three to four ml of 10% formol saline. is was mixed thoroughly and passed through the gauze [14].
ree to four ml of diethyl ether was added and mixed by inverting and intermittent shaking for one minute and then centrifuged at 3,000 rpm for five minutes. After centrifugation, the supernatant (layers of ether, debris, and formol saline) was discarded by a pipette and the sediment (containing the parasites at the bottom of the test tube) was resuspended in formol saline. e sediment was examined microscopically under 10X by 10X and 10X by 40X magnifications for the presence of any parasitic organisms [14]. To maintain the reliability of the study findings, the specimen was reexamined at the end by an experienced laboratory technologist who was blind for the first examination result.

Variables.
e prevalence of the parasitic infections was the dependant variable, while associated risk factors, sociodemographic factors (age, residence, educational level, family size, and religion), socioeconomic factors (occupation, access to clean water, access to the toilet, knowledge about IPIs), environmental factors (source of water), and behavioral factors (hand wash before food and after toilet, eating raw food, personal hygiene, shoe-wearing habit, waste discharge habit, fingernail status) were independent variables.

Data Analysis. Statistical Package for Social Sciences (SPSS) version 25 was used to analyze the collected data.
Descriptive statistics such as frequency, percentage, mean, and range were determined for each intestinal parasite. Binary logistic regression was used to measure the strengths of association between the prevalence of infection and the risk factors using the odds ratio. In the modeling process, a univariate analysis was first carried out with less than a 0.25 level of significance to select the candidate variables for multivariate analysis. e variables, significant at a P-value of <0.25 in the univariate analysis, were then included in the multivariate analysis [15]. Values were considered significant at P < 0.05.

Ethical Consideration.
Ethical clearance was obtained from the Ethical Review Committee of the Science College, Bahir Dar University, before data collection (S1_File). A letter describing the objective of the study was written to the Libokemkem Health Office and Yifag Health Center. e researcher obtained consent from the study participants after explaining the purposes and the procedures of the study.
e laboratory test and the questionnaires were conducted with strict privacy and confidentiality. e pregnant women whose test results are positive were given standard drugs free of charge.

Prevalence of IPIs in the Study Population.
Two species of protozoa and seven species of intestinal helminths were identified from the stool samples of the study participants. e overall prevalence of IPIs was 53.4%. Taenia species (18.1%) and G. lamblia (12.6%) were the two top and E. vermicularis (0.4%) and S. stercoralis (0.4%) were the least prevalent IPIs. e prevalence of protozoa and helminths was 22.0% and 35.7%, respectively. e rates of the single, double, and triple infections were 49.5%, 3.6%, and 0.4%, respectively ( Table 3). Most of the double infections occurred between the Tania species and others, and triple infections occurred among E. histolytica/dispar, G. lamblia, and hookworms.

Factors Associated with IPIs among Pregnant Women
Visiting YHC for ANC. In both the univariate and multivariate logistic regressions, no specific risk factors were observed for E. histolytica/dispar, hookworms, A. lumbricoides, and S. mansoni (P > 0.05). Risk factors were identified to G. lamblia and Taenia species (P < 0.05) ( Table 4). e multivariate logistic regression showed that mothers who had the habit of eating raw vegetables were 2.721 times more infected by G. lamblia (AOR � 2.721; 95% CI: 1.266, 5.849; P � 0.010) than their counterparts, and mothers who had poor personal hygiene were four times more likely infected (AOR � 4.015; 95% CI: 1.456, 11.07; P � 0.007) by G. lamblia than those with good personal hygiene (Table 4). Furthermore, mothers who had the habit of eating raw meat were 2.5 times (AOR � 2.477; 95% CI: 1.252, 4.902; P � 0.009) more likely to be infected by the Taenia species than their contemporaries.
In this study, the prevalence of E. vermicularis was 0.4%. It was consistent with the study conducted in the Gilgel Gibe Dam area, Southwest Ethiopia (0.3%) [18]. However, it was lower than that found in other studies reported from Nigeria (3.5%) [47], Kenya (4.8%) [21], and Venezuela (6.3%) [24] and far lower than Iraq (32.9%) [48]. ese variations in the prevalence of E. vermicularis among studies could be due to the differences in environmental sanitation, parasitological methods used during the study, and maintenance of    personal and community hygiene such as frequent handwashing, fingernail cleaning, regular bathing, and washing of nightclothes and bed lining [45]. High family size, unsafe and inadequate provision of water, unhygienic living conditions, absence or improper utilization of latrine, not washing hands after toilet, and the habit of walking barefoot are significantly associated with IPIs [7,14,22,49]. But these factors did not found to be statistically associated with IPIs in the present study.
In the present study, we found IPIs statistically associated with eating raw meat with the odds of 1.66 (AOR � 1.66; 95% CI: 1.03, 2.67, P � 0.036). is finding is congruent with the study finding around Lake Ziwai, Ethiopia [50].
One of the risk factors for G. lamblia was eating raw vegetables with the odds of 2.72 (AOR � 2.72; 95% CI: 1.27, 5.85; P � 0.010P � 0.010). It is consistent with the study finding in East Wollega, Ethiopia [26]. e other associated risk factor was poor personal hygiene. Mothers with poor personal hygiene were 4.02 times (AOR � 4.015; 95% CI: 1.46, 11.07; P � 0.007) more infected than their counterparts. is report is in agreement with the findings from Jawi Town, Northwest Ethiopia [51], and Goiânia, Goiás State, Brazil [36].
Taenia species was significantly associated with eating raw meat. Mothers who ate raw meat were 2.26 times more infected than their counterparts (AOR � 2.26; 95% CI: 1.13, 4.55, P � 0.02). is finding was supported by the finding from around Lake Ziwai, Ethiopia [50]. However, other identified IPIs were not significantly associated with any of the potential risk factors.

Conclusions
is study indicated that there was a high prevalence of IPIs among pregnant women in the selected area. e most common detected intestinal parasites were Taenia species followed by G. lamblia, E. histolytica/dispar, and hookworms. Eating raw meat was an associated risk factor for IPIs. Eating raw vegetables and poor personal hygiene were predictors of G. lamblia, and eating raw meat was an associated risk factor for Taenia species. So, avoiding eating raw meat and vegetables, making and strengthening sanitation and hygiene programs, creating awareness about IPIs, making closed toilets, and routine deworming of mothers before pregnancy and on second and third trimesters are recommended.

Limitation.
Use of single-season data, use of only wet mount and formol-ether concentration techniques to identify IPIs, and taking stool samples only in the daytime which may affect E. vermicularis load were the limitations of this study.

Data Availability
All the data generated or analyzed during this study are included in this published article (and its supplementary information files).

Conflicts of Interest
e authors have declared that no conflicts of interest exist.