Introduction

Sexually transmitted diseases (STDs) are a group of infectious or communicable diseases in which the primary mode of transmission is through sexual contact ⁽¹⁾ and are among the major causes of illnesses in the world especially in the developing countries ⁽²⁾.

The diseases caused by STDs are classified according to the type of organism causing the infection, which could be bacterial, fungal, viral or of parasitic origin ⁽³⁾. Some of the common sexually transmitted diseases include: Bacterial vaginosis, herpes, Chlamydia, trichomoniasis, gonorrhoea, Hepatitis B virus, HIV and syphilis ⁽³⁾. More than 25 infectious organisms are transmitted primarily through sexual activity and studies reveal that STDs are among the many related factors that affect the broad continuum of reproductive health ⁽⁴⁾.

STDs are characterized as hidden epidemics of tremendous health and economic consequences that can lead to pains, organs damage, serious disabilities such as blindness, deafness, infertility, insanity, paralysis and even death ^{(5) (6)}. Probably of concern to all is that STDs, especially in pregnant women, have been associated with a number of adverse pregnancy outcomes including spontaneous abortion, stillbirth, prematurity, low birth-weight, post partum endometritis, early onset of labour including premature rupturing of membranes, cervical and other cancers, chronic hepatitis, pelvic inflammatory diseases and various sequalae in surviving neonates ⁽⁷⁾. In non-pregnant women, STDs can lead to chronic infertility ⁽⁷⁾.

Documented evidence indicates that STDs can be transmitted from a pregnant mother to the baby, before; during or after the baby’s birth and that some STDs (like syphilis) can cross the placenta and infect the baby in-utero ⁽⁷⁾. Other STDs (like gonorrhoea, chlamydia, hepatitis B viruses and Genital herpes) can be transmitted to the baby during delivery through the birth canal ^{(8) (9)}. HIV can cross the placenta during pregnancy, infect the baby during the birth process and unlike other STDs, can infect the baby through breast feeding ⁽¹⁰⁾.

It is estimated that the number of pregnant women with STDs is increasing by about 250 million a year in the developed countries ⁽¹¹⁾ and double that number in the developing countries ⁽¹²⁾. In spite of the sequalae of these infections, there is inadequate statistical data on the prevalence of STDS in pregnant and non-pregnant women in Calabar, Cross River State. The study objectives were to document the prevalence of these STD organisms before and during pregnancy among women in Calabar and to assess the role of socio-demographic and behavioral risk of the women on STDs.

Materials and Methods

Study location: The study location was Calabar, the capital city of Cross River State. Cross River State is in the south eastern region of Nigeria and shares boundaries with Benue State to the North, Ebonyi and Abia States to the West and to the East by Cameroon Republic. The city has a population of about two million inhabitants and is nicknamed “Canaan City” because of her rich cultural, social life and designated tourist destination.

Collection of samples

Direct examination

Identification of isolates

Results

Out of the 562 pregnant women and 108 non-pregnant women tested, 250(44.5%) and 51(47.2%) were infected with various aetiologic agents respectively.

The prevalence of pathogens detected among pregnant and non-pregnant women is presented in table 1. In pregnant women, Candida albicans had the highest percentage of infection occurrence 121 (21.5%), followed by HIV 38(6.8%) and Chlamydia species, 35(6.2%). Others were Trichomonas vaginalis 29(5.2%); Gardnerella vaginalis (Bacterial vaginosis) 12(2.1%); Hepatitis B Surface Antigen (HBsAg); 8(1.4%) and Treponema pallidum (syphilis) 7 (1.2%). Nesseria gonorrhoea was not isolated.

In the non -pregnant women, Candida albicans also had the highest percentage of infections 23(21.3%) followed by Chlamydia species 11(10.2%); while others in the category were: HIV 9(8.3%); Trichomonas vaginalis 4(3.7%); Hepatitis B surface antigen (HBsAg) 3(2.8) and Gardnerella vaginalis, 1(0.9). Neisseria gonorrhoeae and Treponema pallidum were not isolated among women in that group. Only HIV- 1 was detected in all seropositive HIV samples. There was no statistical significant difference in organisms isolated among the pregnant and non-pregnant women (P>0.05).

Table 2 shows the age specific distribution of pathogens among pregnant women in the study. Pregnant women in the age group of 15-19 years had a higher prevalence rate of 58(74.3%), followed by 20-24 years 78(70.2%) with all of them testing positive to one or more pathogens except Neisseria gonorrhoeae. Women in the age group 25-29 years had infection rate of 54(33.8%); others in the age categories of 30-34 were, 38 (28.1%); 35-39, 17 (29.3%), while those in the age group of 40-49 were the least infected, 5(25.0%). There was a high significant association (P<0.05) between age groups and infection acquisition.

In table 3, the age specific distribution of actual pathogens among the non pregnant women is highlighted. Women in the age categories of 15-19 had infection rate of 3 (37.5%), while those in the age categories of 20-24 had a higher infection rate of 26 (65.0%). Distribution of infection in other age groups were 25-29, 13 (40.6%); 35-39, 3(27.2%) and those in the age group of 40-49 coincidentally like their pregnant counterpart, had the least infection rate; 1 (25.0%). There was equally a high significant association (P<0.05) between age groups and infection rates.

Data in table 4 is on the occurrence of infections according to the educational status of the pregnant and non-pregnant women. Three (3) pregnant women were not educated at any level and all tested positive to infections with Candida species, Hepatitis B Surface Antigen (HBsAg) and HIV giving an occurrence rate of 3(100.0%). An occurrence rate of 5(83.3%) infections was observed among women with Quranic education only and women with primary school education were 123(65.8%). Others were, secondary school certificate holders, 79(34.3%) and higher education, 40(29.4%).

Overall, infection rates were higher in the illiterate pregnant women and in women with low educational background. In the non-pregnant women, infection occurrence was highest among the primary school leavers (FSLC) 26(60.4%), followed by those without any level of education at all, 3(50.0%) and those with secondary (WASC/NECO) 20(39.2%) while those with higher education (HND/DEGREE) were 2(25.0%). Educational status was a significant factor in infection acquisition (P < 0.05).

Table 5 shows the occurrence of infections among the pregnant and non-pregnant women by occupation. Infection rates among the pregnant women were as follows: Unemployed 59(66.3%); Student, 14(50.0%); Businesswomen, 66(47.1%); Civil servants, 48(45.7%) and Housewives 68(31.5%). Housewives recorded the lowest rate of infection occurrence. In the non-pregnant women, students had the highest occurrence of infections 28(65.0%) followed by business women 8(42.1%). Others were unemployed 9(40.9%), civil servants 2(33.3%) and housewives 4(22.2%). Statistically, occupation was significantly associated with infection occurrence (P<0.05).

Influence of perception and awareness of STDs among the pregnant and non-pregnant women was tested and responses comparatively recorded as shown in table 6. Many of the pregnant women were aware of the presence of various types of infections in the general population like HIV/AIDS, gonorrhoea infections, body rashes, genital wounds, ulcers and vaginal itching with discharges. Many were also aware of various boils that women experience in their sexual organs including supposed shaving bumps.

Respondents in the group that were aware of wounds/rashes were 24(36.4%) infected. Others that knew about vaginal discharges in women were 189(51.1%) while women that knew about boils had infection rate of 32(26.7%). Persons who had no idea of what venereal diseases was all about were 5(83.3%) infected. There was a statistical significant difference among pregnant women and level of awareness/ infection perception (P<0.05).

Among the non pregnant women, awareness of STDs and venereal diseases such as wounds/rashes had an infection prevalence of 5(41.6%), knowing about boils was 5(62.5%). Others were vaginal discharges, 38(45.8%) and those that had no idea of STD infections were 3(60.0%). There was no significant difference (P>0.05) in influence and level of awareness among the pregnant and non pregnant women in infection acquisition.

Distribution of infection by circumcision status of pregnant and non-pregnant women is shown in figure 1. Pregnant women who were circumcised had infection rate of 31(77.5%). Others who were not circumcised had a rate of 219(42.0%). In the non pregnant group, circumcised women had infection distribution of 20(60.6%). Uncircumcised women had a corresponding infection distribution rate of 31(41.3%). Circumcision status was significantly associated with infection distribution in pregnant and non-pregnant women (P < 0.05).

Figure 1

Table 1

Figure 2

Table 2

Figure 3

Table 3

Figure 4

Table 4

Figure 5

Table 5

Figure 6

Table 6

Figure 7

FIG. 1: Distribution of infections by circumcision status of pregnant and non-pregnant women in the study.

Discussion

The results of this study have demonstrated the endemicity and occurrence of significant levels of sexually transmitted infections in pregnant and non-pregnant women in Calabar, Cross River State.

Pregnant women have been accepted as a low risk group in terms of STD transmission and as such prevalence level of these infections in them are employed globally as a yardstick for evaluating the trend of such infections within the general population at low risk of getting infected ⁽¹⁴⁾.

A study of the prevalence of STDs in pregnant women is an approximation of the prevalence of these infections in their male counterparts and sexually active non pregnant women ⁽¹⁴⁾. This study has demonstrated that there are no clear disparities with respect to organisms isolated and subsequently STDs among the pregnant and non-pregnant women (P>0.05) in the study as shown in table 1.

The commonest organism encountered in this study was Candida albicans 121(21.5%). This finding is comparable with previous studies on STDs amongst pregnant and non-pregnant women in Illorin ⁽²⁰⁾, Ife ⁽²¹⁾ and Jos, Nigeria ⁽²²⁾.

The prevalence rate of 6.8% recorded for HIV in this study compares favourably with that of the Federal Ministry of Health ⁽¹⁸⁾ Sentinel Study on HIV in pregnant women in Nigeria where a seroprevalence rate of 6.1% was recorded for Cross River State. Elsewhere, higher seroprevalence rate among pregnant women have been reported, for instance, 14.7% in Iquita-Oron in Akwa Ibom State; 13.0% in Makurdi (Benue State) and 10.0% in Saminka (Kaduna State) ⁽¹⁸⁾.

Qualitative TPHA test of the 7 reactive strip samples found significant treponemal antibodies in 5 0f them, absence of significant treponemal antibodies in 2 of these samples tested with TPHA may suggest a non syphilitic reagin antibody production or cross reactions with endemic treponemal infections such as yaws,(T. pertenue), pinta (T. carateum) or bejel (T. endemicum) ⁽²³⁾. The detection of these false positives clearly reveals the non specificity of the rapid test strips and the need for a specific confirmatory test

for syphilis ⁽²⁴⁾, especially as this is not the practice in most hospitals.

Neisseria gonorrhoeae was not isolated among the pregnant and non-pregnant women in this study. This could be attributed to abuse of broad spectrum antimicrobials which can easily be obtained over the counter of patent medicine dealers and pharmacy shops without authorized prescriptions. Non isolation of the organism could also be partly incidental arising from a pool of lightly infected population because of increase condom use and awareness of current incurable HIV pandemic in the world. In contrast, others have found rates ranging from 0.1% in Jos ⁽²²⁾ to o.5% in Kano, Nigeria ⁽²⁵⁾.

Amongst the different age groups investigated, infection distribution was highest in women aged 15-19 years, 58(74.3%) followed by those aged 20-24years, 78(70.2%). The results of this survey is in agreement with generally observed fact that the incidence of STDs by the number of cases treated each year is highest among the 15-24 years old ^{(10), (26), (27)}. Similarly, earlier data from studies by Aboyeyi & Nwabuisi ⁽²⁰⁾, Jombo et al., ⁽²²⁾, Enabulele & Kemajou ⁽²⁸⁾, and Adekanle et al., ⁽²⁹⁾ reported that those in the age group of 15-30 years were the most infected (100%) by one STD or the other in their separate studies. The World Health Organization ⁽³⁾ concludes that this age groups, (15-30years) are persons with the greatest sexual activity and that incidence decreases with age.

The lowest infection rate occurred in housewives in both pregnant and non-pregnant women examined by occupational status and suggests that family life structure could be a major influence.

The high rates observed in applicants, students and other unstable social groups may suggest indiscrete sexual life patterns and multiple sexual partners for monetary rewards. This collaborates the finding by Harding et al., ⁽³⁰⁾ that even though Nigerian students were knowledgeable about STDs, they were not deterred in engaging in risky behaviors.

In many published studies, female circumcision (eg. Female genital mutilation) is always reported to be associated with infection acquisition, especially HIV and syphilis infection ⁽³⁾. Since circumcision is done in traditional settings in many African countries including Nigeria, there is increased risk of exposure to crude, un-sterilized or poorly sterilized instruments which increases the risk of getting infected.

These circumcisions are reported to often involve the removal of the prepuce (clitoral hood) sometimes along with the entire clitoris ⁽³¹⁾. Female circumcision however, in whatever form, has been suggested to facilitate the transmission of sexually transmitted diseases most especially HIV ⁽³⁾. Some of the reasons advanced are that female circumcision may result in genital mutilation which may enhance the transmission of STDs or may present complications during childbirth if labour is obstructed and there is perineal tearing and laceration (32).

Educational status, occupation, circumcision status, use of contraceptive methods, influence and level of perception / awareness of STDs, income levels of pregnant and non-pregnant subjects studied were all significantly linked with infection occurrence and distribution (P<0.05). Meanwhile, marital status, length of union and religion were not significantly associated with infection occurrence (P>0.05).

High STD infection rate among pregnant and non-pregnant women are clear signs that ways to reach those at risk must be developed and promotion of early recourse to health services, especially routine mandatory and early screening of all women for STDs cannot be over emphasized. Proper treatment of all STDs like use of correct and effective medicines, contact tracing and treatment of sexual partners and education of the general populace should not be overlooked in our locality.