Effect of exposure to goats and raw goat products on adverse pregnancy outcomes and perceptions of healthcare providers in Songkhla province, southern Thailand

Abstract

Background: Miscarriage, stillbirth, preterm birth and low birth weight newborn are the most common adverse pregnancy outcomes reflecting the health of women and fetus in utero. Previous studies suggested that these adverse outcomes multifactorial health problems with associated risk factors commonly derived from both maternal and fetal conditions including infections. In many studies, the risk of animal exposures related to adverse pregnancy outcomes were commonly hypothesized especially in endemic areas of some zoonosis such as brucellosis, coxiellosis, and toxoplasmosis which can be carried by small ruminants including goats. However, those studies did not show clear explanation how animal exposure affects pregnancy outcomes. Moreover, perception of healthcare providers, who play a key role in health promotion and disease prevention, is valuable for quality of care by preventing maternal health problems during pregnancy. Health problems in pregnancy due to zoonosis are generally neglected, particularly, by healthcare providers, as healthcare providers' perspective is important for identifying the exposure risk and prevention of zoonosis. Objectives: This study aimed to i) determine the association of history of exposure to goats and their raw products on adverse pregnancy outcomes, ii) assess the seroprevalence of brucellosis, coxiellosis, and toxoplasmosis among pregnant women, and iii) assess the perceptions of healthcare providers on the risk of exposure to goats and their raw products on adverse pregnancy outcomes and their intention to perform risk screening among pregnant women. Methods: To achieve the objectives of the study, the methodology was divided into two parts, which were a prospective cohort study among pregnant women (Part I) and a cross-sectional study among healthcare providers (Part II). Part I was conducted from July 2015 to July 2016 in four districts of Songkhla province. Women who came for their first antenatal care visit, at health centers or hospitals in Thepha, Chana, Saba Yoi, and Na Thawee districts, were invited to participate in the study. Information including a history of exposure to goat or raw goat products (meat or milk) and blood samples were revealed from included women. Adverse pregnancy outcomes were then followed-up. Blood samples of included women were randomly tested for anti- Brucella abortus IgG, but only samples of pregnant women with adverse pregnancy outcome were tested for anti-Coxiella burnetii IgG and anti-Toxoplasma gondii IgG. The association between exposure status (exposed vs non-exposed) and occurrence of adverse pregnancy outcome was analyzed using multiple logistic regression. Part II was also carried out in the same districts which were anonymized as districts A, B, C and D, during October to November 2016. The perception of healthcare providers toward risk of exposure to goat or raw goat products and intention to do risk screening regarding the Health Belief Model components were evaluated. Results: Of 666 pregnant women included in study Part I, the majority of them (74.4%) were aged 20-34 years and Muslim (89.2%). Two hundred and four women (30.6%) had been exposed to goat or raw goat products and 115 (17.3%) had adverse pregnancy outcomes. Of 465 women with blood test, 17 women (3.7%) had seropositive results for anti-Brucella abortus IgG. The association with any adverse pregnancy outcomes was not shown in the exposed group. Higher odds ratios of adverse pregnancy outcomes were found in women having their first antenatal care visit in their first trimester, with a history of preterm birth and low birth weight newborn (adj.OR (95% CI) 2.0 (1.1-3.7), 2.4 (1.0-5.7), and 2.6 (1.3-4.9), respectively). Of 105 serum samples of pregnant women with adverse pregnancy outcomes, 33 samples (31.4%) were seropositive for anti-Toxoplasma gondii IgG, and 2 samples (1.9%) were seropositive for anti-Coxiella burnetii IgG. None of the women were found to be co-seropositive for antibodies against coxiellosis and toxoplasmosis. For Part II of the study, a total of 46 healthcare providers were included. Intention to perform screening, perceived barriers, self-efficacy and cues to action of healthcare providers among the four districts were not significantly different. While perceived susceptibility, perceived seriousness and perceived benefits were significantly different across the four districts with healthcare providers in two districts (districts B and D) rating these items at high levels compared to the other two districts (districts A and C). Perceptions in all components of Health Belief Model of healthcare providers, except perceived barrier, were highly correlated with intention to perform risk screening. Cues to action was the most significant component (p =0.018) correlated with intention to perform risk screening for pregnant women in the linear regression, while the other factors were not related. Conclusion: Although no association between past exposure to goats and their raw products and adverse pregnancy outcomes was found, women with past exposure showed positive anti-Brucella abortus IgG. One-third of pregnant women with adverse pregnancy outcomes were seropositive for toxoplasmosis and a very low prevalence of women with seropositive for coxiellosis was found. Healthcare providers in the study settings had positive perceptions and intention to perform risk screening for exposure to goat or raw goat products in pregnant women. However, specific education and warning of the dangers of endemic zoonosis were strengthening cues to action needed for them. Effective counseling about appropriate animal handling particularly goats is beneficial to prevent relevant health problems of pregnant women.