Abstract

Introduction

The clinical forms of urinary tract infection (UTI) are asymptomatic bacteriuria, cystitis or pyelonephritis. Asymptomatic bacteriuria affects from 2 to 10% of pregnant women, of which between 25 and 35% develop pyelonephritis¹1. Manual Técnico Pré-natal e Puerpério. Atenção Qualificada e Humanizada . Brasília; Ministério da Saúde; 2005. 163 p.. Jacociunas et al.²2. Jacociunas LV, Picoli SU. Avaliação de infecção urinária em gestantes no primeiro trimestre de gravidez. RBAC 2007; 39(1): 55-7.found an incidence of asymptomatic bacteriuria during pregnancy of 16% and Magalhães et al.³3. Magalhães MLC, Furtado FM, Nogueira MB, Carvalho FHC, Almeida FML, Mattar R, et al. Gestação na adolescência precoce e tardia – há diferenças nos riscos obstétricos? Rev Bras Ginecol Obst 2006; 28(8): 446-52.found an incidence of UTI in pregnant adolescents of 6.4%.

UTI during pregnancy occurs due to pelvic dilation and hydroureter, increase in renal size, increase in urine production, change in bladder position from the pelvis to the abdomen, reduction in vesicle muscle tone, and relaxation in the bladder and ureter smooth muscle tissues caused by impregnation with progesterone, glycosuria and aminoaciduria¹1. Manual Técnico Pré-natal e Puerpério. Atenção Qualificada e Humanizada . Brasília; Ministério da Saúde; 2005. 163 p. ^{, 4}4. Heilberg IP, Schor N. Abordagem diagnóstica e terapêutica na infecção do trato urinário. Rev Assoc Med Bras 2003; 49(1): 109-16.. UTI affects pregnant women with similar characteristics, such as primiparous and anemic women and those with a previous history of UTI⁵5. Faria, DGS, Zanetta DMT. Perfil de mães adolescentes de São José do Rio Preto/Brasil e cuidados na assistência pré-natal. Arq Ciênc Saúde 2008; 15(1): 17-23. ^{, 6}6. Duarte G, Marcolin AC, Gonçalves CV, Quintana SM, Berezowski AT, Nogueria AA et al. Infecção urinária na gravidez: análise dos métodos para diagnóstico e do tratamento. RBGO 2002; 24(7): 471-77. The main complication of UTI during pregnancy is preterm birth. UTI can also cause intrauterine growth restriction, low birth weight, cerebral palsy, mental retardation, infection, multiple organ failure and death. Additionally, UTI can cause severe maternal complications such as cellulite, perinephric abscess, urinary obstruction, premature labor, premature membrane rupture, anemia, chorioamnionitis, endometritis, septic shock, multiple organ failure and death⁷7. Polivka BJ, Nickel JT, Wilkins JR 3rd. Urinary tract infection during pregnancy: a risk factor for cerebral palsy? J Obstet Gynecol Neonatal Nurs 1997; 26(4): 405-13. ^{- 8}8. McDermott S, Callaghan W, Szwejbka L, Mann H, Daguise V. Urinary tract infections during pregnancy and mental retardation and developmental delay. Obstet Gynecol 2000; 96(1): 113-19..

The diagnosis of UTI must be performed with the laboratory test of urine culture, considered as the gold standard. There are other rapid tests to indicate urinary infection, such as the type 1 test and urine coloration with the Gram method. The type 1 test must be routinely requested in the first prenatal consultation and repeated close to the 30^thgestational week. If this test detects bacteria, leukocytes or piocytes, urine culture must therefore be requested¹1. Manual Técnico Pré-natal e Puerpério. Atenção Qualificada e Humanizada . Brasília; Ministério da Saúde; 2005. 163 p..

Adequate prenatal care interventions contribute to reduce the complications caused by UTI during pregnancy. Performing routine urine tests during prenatal care in asymptomatic pregnant women to identify and treat those with asymptomatic bacteriuria benefits both these women and newborns. A systematic review showed that the treatment for asymptomatic bacteriuria reduced the risk of pyelonephritis and low birth weight, although it did not influence preterm birth rates⁹.

In 2009, the proportion of newborns with low birth weight in the city of Rio de Janeiro was 10%. ( http://tabnet.datasus.gov.br/cgi/tabcgi.exe?idb2010/g16.def ). It is possible that many newborns have come from pregnant women with UTI inadequately treated during prenatal care.

The present study develops an in-depth and innovative approach towards the assessment of the adequacy of management of UTI during prenatal care. This approach is different as it verifies such management according to several joined dimensions which have not been observed in the literature, namely the assessment of health professionals, health services and pregnant women, according to the Ministry of Health recommendations¹1. Manual Técnico Pré-natal e Puerpério. Atenção Qualificada e Humanizada . Brasília; Ministério da Saúde; 2005. 163 p.. The main hypothesis is that health professionals are those largely responsible for the difficulties in providing adequate prenatal care regarding urinary tract infections.

Methods

Study population

A cross-sectional study was conducted between October 2007 and May 2008. The participants were pregnant women who sought prenatal care at the Unified Health System ( Sistema Único de Saúde – SUS) units in the city of Rio de Janeiro, RJ, Southeastern Brazil.

Sampling

A two-stage cluster sampling was performed to recruit the sample. In the first stage, SUS health care units providing low-risk prenatal care in the city of Rio de Janeiro were selected. In the second stage, pregnant women from these health care units were drawn. The sample was comprised of 1,313 women from primary health care units, 832 from hospitals or maternity hospitals and 73 from a maternity clinic, totaling thus 2,218 pregnant women. More details regarding the sampling procedures used in this study can be found in Vettore et al.¹⁰.

Data collection

Data were collected through interviews using a standardized questionnaire and from information available in the prenatal care card. The selected pregnant women were interviewed by health professionals and undergraduate students, previously trained and under supervision in the health care unit itself.

All questionnaires and prenatal care cards were reviewed by physicians with experience in prenatal care for the identification of pregnant women with urinary tract infection (UTI), anemia, diabetes and history of preterm birth, stillbirth and/or neonatal mortality. The inclusion criteria were as follows: to have the prenatal care card, to bring the prenatal care card on the day of the interview, and to be categorized into with or without UTI. The exclusion criteria were as follows: lack of urine test, lack of records of urine tests in the prenatal care card or lack of treatment recorded in the prenatal care card and/or reported by the patient.

The present study was approved by the Research Ethics Committee of the Sergio Arouca National School of Public Health (ENSP/FIOCRUZ), protocol 142/06.

Study variables

The interviews included information about age; ethnicity; level of education; marital status; paid job; number of previous pregnancies; pre-pregnancy nutritional status; obstetric history; history of anemia and diabetes; gestational age in the beginning of prenatal care; explanation about the risk of UTI; request for urine test before and after treatment and performance of this test in a SUS unit; and prescription, obtained in a SUS unit and use of medication for UTI treatment. Finally, the Kotelchuck index, which is used to assess the adequacy of prenatal care, was calculated¹¹11. Kotelchuck M. An evaluation of the Kessner Adequacy of Prenatal Care Index and a proposed adequacy of prenatal care utilization index. American Journal of Public Health 1994; 84(9): 1414-20.. In addition to the interview, prenatal care cards of all pregnant women included in the study were also copied manually or using copying services. Records of gestational age, weight, results of complementary tests of ATE (Abnormal Trace Elements), urine culture, blood glucose, hemoglobin, hematocrit, obstetric ultrasound and records of UTI treatment.

The following were considered as cases of UTI during pregnancy: pregnant women with positive urine culture recorded in the prenatal care card or those with altered ATE results (with 12 or more pyocites per field, piuria or uncountable pyocites, positive nitrite) recorded in the prenatal care card or record of UTI treatment in the prenatal care card or pregnant women's report of having had UTI and having been prescribed treatment during the current pregnancy¹1. Manual Técnico Pré-natal e Puerpério. Atenção Qualificada e Humanizada . Brasília; Ministério da Saúde; 2005. 163 p..

The comparison group comprised pregnant women without UTI who were receiving prenatal care in the same health care units and for which the same diagnostic criteria were used.

All pregnant women classified as cases of UTI in the current pregnancy had the management of their condition independently assessed by two obstetricians. Any disagreements were resolved by consensus.

Considering the recommendations of the Prenatal and Postnatal Care Technical Manual¹, the management of UTI during pregnancy was classified as adequate or inadequate, according to the criteria presented in the table below.

Analysis

Initially, sample weights were estimated taking into account the type of health care unit. They were used to adjust for sampling complexity. The associations of characteristics of pregnant women at risk of UTI were tested using the chi-square test, considering a significance level of 5%. Independent variables that had a p-value below 0.20 were selected for multivariate logistic regression for the assessment of risk of UTI. Odds Ratio (OR) and respective 95% confidence intervals (95%CI) were estimated. Chi-square tests were performed to test the associations between characteristics of pregnant women with UTI and the results of prenatal care management. Variables that had a p-value below 0.20 were included in the multivariate logistic regression for the assessment of UTI management. Initially, separate analyses of health professionals, health services and pregnant women were performed, followed by an overall analysis.

The SPSS (Statistical Package for the Social Sciences) software, version 17.0, was used in all statistical analyses.

Results

Profile of pregnant women

A total of 2,188 pregnant women were selected: 92 (4.2%) refused to participate in the study and 1,005 (45.9%) were excluded as it was not possible to assess their risk of UTI. Thus, the final sample was 1,091 (46.8%) pregnant women, 501 (45.9%) classified as UTI cases and 590 (54.1%) without UTI.

The assessment of the profile of pregnant women revealed statistically significant differences between those with UTI and without UTI regarding age, marital status, anemia, diabetes and gestational age in the beginning of prenatal care ( Table 1 ).

UTI was more frequent in younger pregnant women. Among those with UTI, the proportion of pregnant women younger than 19 years was 1.4 times higher than those without UTI (p = 0.01). Most of them (76%) lived with a partner and these had less UTI than others who did not have a partner. In all, 26.5% of pregnant women had anemia and this was 2.5 times more frequent in those with UTI. Diabetes was also more frequent in the group of pregnant women with UTI (p = 0.01), although only 2% of the sample presented such condition. There was no available information concerning diabetes for 360 pregnant women. The beginning of prenatal care occurred in the first trimester for 64% of pregnant women; those with UTI began prenatal care at a later time.

The Kotelchuck index¹¹11. Kotelchuck M. An evaluation of the Kessner Adequacy of Prenatal Care Index and a proposed adequacy of prenatal care utilization index. American Journal of Public Health 1994; 84(9): 1414-20., which assess the adequacy of prenatal care, revealed that 84% of all pregnant women had adequate or more than adequate prenatal care. Pregnant women with UTI had a poorer performance, as 24% of them fell into the partially adequate and inadequate prenatal care categories, a significantly higher percentage than the 9% of those who did not have UTI.

Mixed ethnicity predominated in both groups and the majority of pregnant women had completed primary education and did not have a paid job. In all, pregnant women with one or two previous pregnancies, with a normal body mass index (BMI), and without history of prematurity, stillbirth and neonatal-mortality predominated. Obstetric history of prematurity, stillbirth and neonatal-mortality was assessed in only 55% of pregnant women as 39% were primiparous and no information could be obtained from the remaining 6.6%. There were no significant differences between groups with regard to ethnicity, level of education, paid job, number of previous pregnancies, pre-pregnancy nutritional status, and history of preterm birth, stillbirth and/or neonatal-mortality.

Results of the logistic regression analysis of the socio-demographic profile of pregnant women with UTI

In the multivariate regression analysis, the variables that showed statistical significance were gestational age, anemia, diabetes and the Kotelchuck index¹¹11. Kotelchuck M. An evaluation of the Kessner Adequacy of Prenatal Care Index and a proposed adequacy of prenatal care utilization index. American Journal of Public Health 1994; 84(9): 1414-20..

The odds of having UTI during prenatal care were 1.79 times higher among adolescents than those aged between 20 and 34 years (95%CI: 1.12 – 2.88, p = 0.02). Pregnant women with anemia had a higher odds of having UTI than those without anemia (OR = 1.83; 95%CI: 1.23 – 2.72, p = 0.01), as did women with diabetes when compared to those without diabetes (OR = 3.56; 95%CI: 1.25 – 10.19, p = 0.02). Pregnant women classified as having had partially adequate or inadequate prenatal care, according to the Kotelchuck index⁹9. Smail FM, Vazquez JC. Antibiotics for asymtomatic bacteriuria inpregnancy . Disponível em http://cochrane.bvsalud.org/cochrane/main.php?lib=COC&searchExp=bacteri%FAria&lang=pt DOI: 10.1002/14651858. (Acessado em 22 de agosto de 2011).
http://cochrane.bvsalud.org/cochrane/mai... , were 1.6 times more likely to have UTI during prenatal care than those with adequate or more than adequate prenatal care (OR = 1.55; 95%CI: 1.03 – 2.33, p = 0.04).

Results of UTI management

Initially, an assessment was made of professionals' management dimension. In the group of pregnant women with UTI, 53% reported having received information about the risks of UTI during pregnancy. Requesting urine tests was reported by 75% of pregnant women and 96% said they had received medications for UTI treatment. A new urine test for control after UTI treatment was requested for 67% of pregnant women ( Table 2 ).

As shown in Table 2 , the assessment of health services reveals that the urine test was made available in the SUS for the great majority of pregnant women (98%) and medications for UTI treatment were made available for 72% of those who sought to obtain them.

With regards to the assessment of the pregnant women's dimension, among those who had been requested a urine test, 94% managed to have it performed. Of the 376 women who received medications for UTI treatment, 81% had sought to obtain the prescribed medications and 85% had taken these medications.

The overall assessment of UTI management during pregnancy could be made with 496 pregnant women and 358 (72%) of them had their management considered to be inadequate. The dimension of management of health professionals showed the highest proportion of inadequacy (390 pregnant women, 63%). The performance of the health care units could be observed among 482 pregnant women and 110 (23%) had an inadequate UTI management. Of all 492 women assessed for the pregnant women's dimension, 40 (8%) had an inadequate UTI management.

Results of the pregnant women's profile with regard to UTI management and logistic regression of the assessment of this management during prenatal care, in the SUS, in the city of Rio de Janeiro

Pregnant women with low weight had a lower proportion of inadequate follow-up of UTI during prenatal care, when compared to those with a normal weight (p = 0.05) ( Table 3 ).

There was a trend towards inadequate UTI management during prenatal care for pregnant women who were older and of brown ethnicity, with a lower level of education, with a partner, with a paid job, with at least one previous pregnancy, with a history of prematurity, with anemia, without a history of stillbirth and/or neonatal mortality, and without diabetes. There was no available information about diabetes and anemia for 269 and 165 pregnant women, respectively.

As shown in Table 4 , according to the health professionals' dimension, pregnant women with low weight and those with overweight and obesity had lower odds of inadequate UTI management (OR = 0.45; 95%CI: 0.25 – 0.81 p = 0.01; OR = 0.58; 95%CI: 0.33 – 0.99, p = 0.05, respectively) than those with a normal weight. The assessment of management of health services did not show statistically significant differences between the variables studied. With regard to the assessment of the dimension of pregnant women, the odds of inadequate UTI management were three times lower for primiparous pregnant women than those with one or more children (OR = 0.31; 95%CI: 0.12 – 0.76, p = 0.01).

In the overall assessment, ethnicity was the variable that had statistical significance (p = 0.01) ( Table 5 ). The odds of experiencing inadequate UTI management during prenatal care were 2.5 times higher among mixed women than white ones (OR = 2.53; 95%CI: 1.31 – 4.87, p = 0.01).

Discussion

The proportion of pregnant women with urinary tract infection was 46%. Narchi et al.¹², through interviews and prenatal care card analysis, found a rate of UTI during pregnancy of 51%. However, Leal et al. reported a rate of 19.2% of UTI during pregnancy, with data collected from patients using public services¹³13. Leal MC, Gama SGN, Campos MR, Cavalini LT, Garbayo LS, Brasil CLP et al. Fatores associados à morbi-mortalidade perinatal em uma amostra de maternidades públicas e privadas do Município do Rio de Janeiro, 1999-2001. Cad Saúde Pública 2004; 20(S1): 20-33.. In a study that included the prenatal care card as a source of information about UTI during pregnancy, the findings reported in the literature were similar to those from the present study, i.e. only the self-reported information underestimates the prevalence of UTI. Future studies should consider other sources of information, such as prenatal care cards.

Among the pregnant women who had UTI, 28% were adolescents and they were more affected by this condition than those aged more than 35 years. Cabral et al. found that UTI was more frequent among adolescent pregnant women¹⁴14. Cabral ACV, Peixoto RML, Miranda SP, Vieira E. Gravidez e adolescência. J Bras Ginecol 1985; 95(6): 251-53.. Faria et al. observed a rate of 35.7% of UTI among adolescent pregnant women⁵.

Anemia was more frequent in the UTI group. Duarte et al. found that 57% of pregnant women with pyelonephritis had anemia¹⁴14. Cabral ACV, Peixoto RML, Miranda SP, Vieira E. Gravidez e adolescência. J Bras Ginecol 1985; 95(6): 251-53.. Diabetes was more frequently found in the UTI group. Alvarez et al. observed that the incidence of asymptomatic bacteriuria was 2.5 times higher in diabetic pregnant women than those without diabetes¹⁵15. Alvarez JR, Fechner AJ, Williams SF, Ganesh VL, Apuzzio JJ. Asymptomatic bacteriuria in pregestational diabetic pregnancies and the role of group B streptococcus. Am J Perinatol 2010; 27(3): 231-4..

The worst assessment was that of health professionals, with 62% of inadequacy. What most contributed to this poor performance was the explanation about the risks of UTI during pregnancy. This assessment could have been influenced by the level of education of the pregnant women and difficulty of health professionals in establishing a dialogue and making themselves understood by pregnant women with poor schooling. Nonetheless, satisfaction with the health service did not differ between pregnant women with primary education level and those with more than eight years of education. The routine urine test performed during prenatal care, ATE or urine culture, was requested for 75% of pregnant women and 96% of those with UTI have received prescriptions for UTI treatment. Only half of pregnant women with UTI reported having received explanations about the risks of pregnancy. This result suggests that there is little communication between professionals and patients, perhaps due to the excessive number of appointments, where the medical practice is directed towards requesting tests and prescribing treatments. After the treatment, in 1/3 of the cases there was no request for a new urine test to control the infection, as recommended by the Ministry of Health¹1. Manual Técnico Pré-natal e Puerpério. Atenção Qualificada e Humanizada . Brasília; Ministério da Saúde; 2005. 163 p.. Pregnant women with low weight, overweight or obesity received better prenatal care from health professionals than those with a normal weight, thus revealing their concern with those pregnant women at risk.

There was a wide availability of urine tests in the public health services, totaling 98%. In 2006, 90.5% of pregnant women who had live newborns in Southeastern Brazil had a urine test performed during prenatal care. However, 28% of patients could not obtain medications for their treatment¹⁶16. Pesquisa Nacional de Demografia e Saúde da Criança da Mulher – PNDS 2006; dimensões do processo reprodutivo e da saúde da criança. Brasília: Ministério da Saúde; 2009.. UTI treatment during pregnancy reduces the risk of complications. In addition to benefiting patients, outpatient treatment is less expensive than hospital treatment.

Compared to health professionals and services, pregnant women were those who had the best performance of adequacy of prenatal care for UTI. Primiparous pregnant women performed better than those who had at least one child. Additionally, they appear to show more concern and care for their pregnancy than those who already have children. The majority of pregnant women (81%) sought to obtain prescribed medications in the SUS and 85% reported they had taken their medications. This difference could have occurred because some of them obtained their medications from a different source or because of information bias in the responses given to the use of medications to treat UTI.

Pregnant women with anemia and diabetes had greater odds of having UTI during prenatal care. However, these conditions were not sufficient to provide them a better prenatal care. Ethnicity was the crucial characteristic for a better or worse management of UTI during prenatal care. Brown pregnant women had a poorer prenatal care follow-up than the white ones in the overall UTI assessment. Leal et al.¹⁷17. Leal MC, Gama SGN, Cunha CB. Desigualdades raciais, sociodemográficas e na assistência ao pré-natal e ao parto, 1999-2001. Rev Saúde Pública 2005; 39(1): 100-7.reported the persistent unfavorable condition of black and brown women regarding prenatal care when compared to white women, in the city of Rio de Janeiro. In the inadequate prenatal care category, according to the Kotelchuck index⁹9. Smail FM, Vazquez JC. Antibiotics for asymtomatic bacteriuria inpregnancy . Disponível em http://cochrane.bvsalud.org/cochrane/main.php?lib=COC&searchExp=bacteri%FAria&lang=pt DOI: 10.1002/14651858. (Acessado em 22 de agosto de 2011).
http://cochrane.bvsalud.org/cochrane/mai... , values were significantly higher among black and brown pregnant women than the white ones. Silveira et al. observed that the prevalence of non-performance of urine tests was 10% among poor and black pregnant women with low schooling and 0.4% among rich and white women with high schooling¹⁸18. Silveira MF, Barros AJD, Santos IS, Matijasevich A, Victora CG. Diferenciais socioeconômicos na realização de exame de urina no pré-natal. Rev Saúde Pública 2008; 42(3): 389-95..

Pregnant women without history of stillbirth and/or neonatal-mortality were more likely to receive worse follow-up of UTI management than those with this obstetric history. It seems that pregnant women with an obstetric history of risk are better cared because of the awareness of the consequences of not investigating and treating UTI during pregnancy. Mazor-Dray et al. found an independent association between UTI and Intrauterine Growth Restriction (IUGR), pre-eclampsia, Cesarean section and premature birth¹⁹19. Mazor-Dray E, Levy A, Schlaeffer F, Sheiner E. Maternal urinary tract infection: is it independently associated with adverse pregnancy outcome? J Matern Fetal Neonatal Med 2009; 22(2): 124-8..

One limitation of this study was the fact that half of the sample was excluded due to the impossibility of the assessment of the risk of UTI, which may have caused a selection bias. The comparative analysis between the excluded and included groups in this study showed no differences regarding age, marital status, parity, nutritional status, history of prematurity, stillbirth and/or neonatal-mortality, and gestational age in the beginning of prenatal care. However, there were differences between groups in respect to ethnicity, level of education, paid job, anemia, diabetes and adequacy of prenatal care, according to the Kotelchuck index. The following characteristics were more frequently excluded: black pregnant women with a lower level of education, without a paid job, with anemia and diabetes, and with partially adequate or inadequate Kotelchuck indices. Even when excluding pregnant women with anemia, diabetes and partially adequate or inadequate Kotelchuck indices, these characteristics maintained their association with risk of UTI during prenatal care. With regard to the black ethnicity, if this difference had not occurred when patients were selected, this ethnicity could have been included with brown pregnant women in the overall assessment of UTI management as a factor associated with inadequate management, and a different result could have been obtained in the assessments of UTI management of health care services and pregnant women. Level of education, which also showed different exclusions, was almost significant in the assessment of UTI management of pregnant women (p = 0.09). It is possible that, if such exclusions had not occurred in this way, this variable could have been statistically significant. With these exclusions, an underestimation of association measures may have occurred.

Based on these results, it is recommended that health care services should promote training for health professionals about a more humane care for pregnant women. Additionally, continuing education about the relevance of UTI during pregnancy should be provided to these professionals, with an emphasis on potential negative repercussions, aiming to promote the performance of urine tests during prenatal care. It is also suggested that the number of prenatal care services should be readjusted in the health care units, aiming to enable more time for explanations about the risks of UTI during pregnancy. Moreover, it is important to draw the attention of public health authorities towards the need for a regular supply of medications for UTI treatment during pregnancy.

The findings of the present study are only valid for women who were followed during prenatal care and, consequently, these results must be better than those obtained for the general population, which includes pregnant women without such follow-up.

Conclusions

The pregnant women who were more likely to have UTI during prenatal care were adolescents and those with anemia, diabetes and a partially adequate or inadequate quality of prenatal care, according to the Kotelchuck index⁹9. Smail FM, Vazquez JC. Antibiotics for asymtomatic bacteriuria inpregnancy . Disponível em http://cochrane.bvsalud.org/cochrane/main.php?lib=COC&searchExp=bacteri%FAria&lang=pt DOI: 10.1002/14651858. (Acessado em 22 de agosto de 2011).
http://cochrane.bvsalud.org/cochrane/mai... .

The proportion of adequate UTI management during prenatal care was low. Health professionals were the factor that most contributed to inadequate UTI management. There was a deficiency in the supply of medications for UTI treatment during pregnancy in the public health care system in Brazil. In general, pregnant women with UTI adhered to the recommendations to have a good prenatal care follow-up.

With regard to UTI management, the prenatal care follow-up was worse among brown pregnant women than white ones in the overall assessment. Pregnant women with low weight, overweight and obesity were less likely to have inadequate UTI management during prenatal care than those with a normal weight in the assessment of health professionals. In the assessment of pregnant women, primiparous pregnant women had a lower risk of inadequate UTI management than those with one or more children.

References

Publication Dates

History