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Global Prevalence of Helicobacter Pylori Infection in Pregnant Women: A

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 http://www.ijwhr.net doi 10.15296/ijwhr.2017.06
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Open Access
Open Access Systematic
ReviewReview
International
International Journal
Journal of Women’s
of Women’s HealthHealth and Reproduction
and Reproduction Sciences
Sciences
Vol.Vol.
3, No. 3, July
5, No. 2015, 126–131
1, January 2017, 30–36
ISSN 2330-
ISSN 4456
2330- 4456

Women on
Global the Other Side
Prevalence of War and Poverty:
of Helicobacter pylori Its Effect in
Infection
on the Health
Pregnant Women: of Reproduction
A Systematic Review and Meta-analysis
Study
Ayse Cevirme , Yasemin Hamlaci , Kevser Ozdemir
1 2* 2

Abstract
Milad Azami1, Marzieh Parizad Nasirkandy2, Akram Mansouri3, Zahra Darvishi4, Shoboo Rahmati1,
War and poverty are5 ‘extraordinary conditions created by human intervention’ and ‘preventable public health problems.’ War and
Ghobad Abangah , Hamid Reza Dehghan6, Milad Borji1, Shamsi Abbasalizadeh2*
poverty have many negative effects on human health, especially women’s health. Health problems arising due to war and poverty are
being observed as sexual abuse and rape, all kinds of violence and subsequent gynecologic and obstetrics problems with physiological
Abstract
and psychological courses, and pregnancies as the result of undesired but forced or obliged marriages and even rapes. Certainly,
unjust treatment
Objectives: such aswomen
Pregnant being unable to gainthe
are among footing
moston the land itgroups
vulnerable is livedfor
(asylum seeker, refugee,
Helicobacter etc.) and being
pylori infection. The deprived
infectionofmay cause
social security,
nausea, citizenship
vomiting, anemia,rights
fetaland human
growth rights brings
restriction, about
fetal the deprivation
anomalies and lowofbirth
accessweight
to health services and
of infants. of provision
H. pylori of
prevalence during
service intended
pregnancy is varyforwidely
gynecology anddifferent
between obstetrics.geographical
The purpose regions
of this article is to address
and given effects of of
the importance warthis
andinfection
poverty on
in the health ofsystematic
pregnancy,
reproduction
review of women andhas
and meta-analysis to offer
beenscientific
done. contribution and solutions.
Keywords:and
Materials Poverty, Reproductive
Methods: health,study
The current War has been conducted based on PRISMA guideline. The time interval of the investigated
studies was from the beginning of 2000 until March 2016. In order to achieve the related literature, databases sources such as Scopus,
PubMed, Science Direct, Cochrane, Embase, Springer, Wiley online library, as well as Google Scholar search engine was used. The
search was done using Mesh keywords. Furthermore, all the articles
Introduction that met
thought thatthe inclusion
severe criteria
military were evaluated.
conflicts in AfricaThe data has been
shorten
analyzed using
Throughout thethe random-effects
history models
of the world, the for
ones meta-analysis
who had andthe theexpected
Stata 11.1.lifetime for more than 2 years. In general,
Results: In the
confronted 24 studies,
bitteresta face
total of
of poverty
19426 pregnant
and warwomen
had al-had been
WHO investigated. The worldwide
had calculated of H. pylori
prevalencepeople
that 269 thousand infection in
had died
pregnant women was calculated to be 46% (95%
ways been the women. As known poverty and war affects CI: 38-54). The lowest prevalence of H. pylori infection was seen in
in 1999 due to the effect of wars and that loss of 8.44 mil- Europe, 25%
(95% CI: 9-40) and the highest prevalence in South
human health either directly or indirectly, the effects of America 62% (95% CI: 53-71).
lion healthy years of life had occurred (2,3).
Conclusion:
this conditionThis meta-analysis
on health and statusshows that about
of women half
in the so-of the Wars
pregnant womenaffect
negatively worldwide are infected
the provision with H.
of health pylori and the
services.
prevalence of this infection in South America
ciety should not be ignored. This study intends to cast and Africa is far more than other continents.
Health institutions such as hospitals, laboratories and
Keywords:
light on the effects of warHelicobacter
Prevalence, and povertypylori,
on thePregnant women, Systematic
reproductive Review,
health centers areMeta-Analysis
direct targets of war. Moreover, the wars
health of women. For this purpose, the face of war affect- cause the migration of qualified health employees, and
ing the women, the problem of immigration, inequalities thus the health services hitches. Assessments made indi-
Introduction
in distribution of income based on gender and the effects incidence
cate that of of
the effect gastric cancerininthe
destruction developed countries
infrastructure of (6,7).
of all these onpylori
Helicobacter the reproductive health of bacillus
is a gram-negative women will be to
known health continues for 5-10of
The prevalence years
thiseven after the
infection is finalization
related to econom-
addressed.
be colonized in the stomach and play a role in the creation of conflicts
ic and (3). Duefactors,
social to resource requirements
including incomein level
the re-and living
of multiple gastrointestinal disorders which is the most structuring investments
conditions duringafter war, the share
childhood, poor allocated
hygiene, toand over-
War and Women’s Health
common chronic infection around the world (1). Preg- healthcrowding has decreased (1).
(8,9). H. pylori prevalence during pregnancy is
Famine, synonymous with war and poverty, is clearer for
nant women are among the most vulnerable
women; war means deep disadvantages such as full de-
groups to the vary widely between different geographical regions (4,5).
Mortalities and Morbidities
mentioned infection;which has been shown
struction, loss of future and uncertainty for women. Wars with nausea, So, the increasing
The ones who are most affectedimportance
from wars of are
thewomen
subjectanddemands a
vomiting, anemia, fetal growth restriction, fetal
are conflicts that destroy families, societies and cultures anomalies children. While deaths depending on direct violence af-to put all
systematic review and meta-analysis in order
and
that low birth weight
negatively affect the(2,3).
health of community and cause themale
fect the relevant documents
population, together
the indirect deathsandkillpresenting
children, a com-
In general,
violation theserights.
of human bacteria have infected
According more
to the data than 50% women
of World plete
andpicture of thisInproblem
elders more. in pregnant
Iraq between 1990-1994, women
in- around
Health
of Organization
the population in (WHO)
the world and(2).
World
Various in 2002from fant deaths
Bank,studies had (10,11).
the world shown this reality in in
Therefore, itsthe
more bare form
current study, which
wars hadgeographical
different been among the first has
regions ten reported
reasons which killed
the prevalence with aimed
an increase of 600%the
to estimate (4).prevalence
The war taking
of H. five years
pylori infection in
the most and caused disabilities. Civil losses are
of H. pylori during pregnancy in the range of 7.6 % to 94%at the rate increases the child deaths under age of 5 by 13%.
pregnant women, systematic review and meta-analysis Also 47% has
of 90%
that 7.5%within all losses
to 42.9% been seen in European countries, of allbeen
has(1). the refugees
used. in the world and 50% of asylum seekers
War has many negative effects on human health. One of and displaced people are women and girls and 44% ref-
in Asian countries 24% to 61%, in the American countries
these is its effect of shortening the average human life. ugees and asylum seekers are children under the age of
50% to 70%toand
According in Africa
the data of WHO,morethethan 52%human
average (4,5). life is Materials and Methods
18 (5).
In general, countries with high rates of stomach
68.1 years for males and 72.7 years for females. It is being cancer As theTheresult
current studyand
of wars hasarmed
been done based
conflicts, on PRISMA
women are (Pre-
have a higher prevalence of infection with H. pylori and ferred reporting items for systematic reviews and me-
reduction in the prevalence of this bacteria reduced the ta-analyses) guideline (12). In order to avoid bias, factors
Received 12 December 2014, Accepted 25 April 2015, Available online 1 July 2015
1
Department of Nursing, Sakarya University, Sakarya, Turkey. 2Department of Midwifery, Sakarya University, Sakarya, Turkey.
Received 10 July 2016,
*Corresponding Accepted
author: Yasemin 22 December
Hamlaci, 2016, Available
Department online
of Midwifery, 1 January
Sakarya 2017 Sakarya, Turkey. Tel: +905556080628,
University,
Email: yaseminhamlaci@gmail.com
1
Student Research Committee, Ilam University of Medical Sciences, Ilam, Iran. 2Women’s Reproductive Health Research Center, Tabriz University
of Medical Sciences, Tabriz, Iran. 3School of Nursing and Midwifery, Ahvaz Jundishapour University of Medical Science, Ahvaz, Iran. 4Clinical
Microbiology Research Center, Ilam University of Medical Sciences, Ilam, Iran. 5Department of Internal Medicine, Ilam University of Medical
Sciences, Ilam, Iran. 6Health Technology Assessment Department, Yazd Cardiovascular Research Center, Shahid Sadoughi University of Medical
Sciences, Yazd, Iran.
*Corresponding Author: Shamsi Abbasalizadeh,Women’s Reproductive Health Research Center, Tabriz University of Medical Sciences, Tabriz,
Iran. Tel: +989143028867; Email: sabbasalizadeh@yahoo.com
Azami et al
such as search, selection of studies, quality assessment and
data extraction were done by two researchers independent
of each other.
Data Sources
This study is a first systematic review and meta-analysis
study. The results of this study are based on articles pub-
lished in journals. The studies that have been reviewed
were conducted from the beginning of 2000 until March
2016. In order to achieve the related literature, database
such as Scopus, PubMed, Science Direct, Cochrane, Em-
base, Springer, Wiley online library, as well as Google
Scholar was used. The search was done using Mesh key-
words. These keywords included Prevalence, Helicobacter
pylori, Helicobacter infections, pregnant women, preg-
nancy, pregnancy complications, gestational which was
also searched in combination by using AND and OR oper-
ators. A sample of PubMed search is shown in Appendix 1.
Inclusion and Exclusion Criteria
The main criterion for inclusion was investigated on the
prevalence of H. pylori in the population of pregnant
women. Exclusion criteria included (a) the non-random
sample size, (b) not relating to the topic, (c) insufficient
data, (d) date of the study, which was not between 2000
and 2016, and (e) Diagnosis was not based on laboratory
findings.
Definitions
The diagnosis of H. pylori according to the laboratory
findings contained serology, urea breath test, stool antigen
or polymerase chain reaction (PCR) (8,9).
Qualitative Assessment
Two researchers independently used STROBE (The
Strengthening the Reporting of Observational Studies in
Epidemiology) (13) checklist which is an international
and a standard checklist for qualitative assessment of stud-
ies and investigated the selected articles on various aspects
of the methodology, including sampling techniques, vari-
able measurements, statistical analysis and the aim of the
study. The authors adopted a simple method for rating.
Two points were given to each part of the checklist and
at the end, the given points to the papers were compared
by two researchers and in the case of differences a third
researcher would do it all over again. The minimum point
that would be given was 16 and those articles that meet the
quorum qualitative assessment score were considered for
the meta-analysis process.
Data Extraction
All final papers which were accepted for the study were
extracted by a prepared checklist. The check-list includ-
ed the author’s name, year of study, place of study, study
design, sample size, age, gestational age, a method of diag-
nosis of H. pylori infection and also the prevalence of H.
pylori infection in pregnant women.
International Journal of Women’s Health and Reproduction Sciences, Vol. 5, No. 1, January 2017
Statistical Analysis
In each study, the prevalence of H. pylori was considered
as the probability of binomial distribution and its vari-
ance was calculated from the binomial distribution. To
assess the heterogeneity of the studies, Cochrane test, and
I2 index were utilized. Heterogeneity in the study was
measured 99%, which puts the study among highest het-
erogeneity studies (I2 index less than 25% represents low
heterogeneity, between 25%-75% average and more than
75% represents high heterogeneity). The DerSimonian
and Laird method in the random-effect model were used
to generate a 95% CI, which takes study heterogeneity into
account to obtain the estimates. Regarding the heteroge-
neity of the studies and the significance of the I2 score,
random effects size model in the meta-analysis was used
(14). Data were analysis using Stata version 11.1 software
and the significant level was set at 0.05.
Results
In the systematic review 610 articles were identified which,
after examining the titles, 280 articles were excluded due
to being a duplicated study. So the full text of 330 arti-
cles was examined and after checking the inclusion and
exclusion criteria, finally 24 articles that have been done
between the years 2000 to 2014 were decided to be quali-
fied which entered into the final meta-analysis (Figure 1).
In total 19426 pregnant women had participated in the
study. Details of the studies that were entered into the me-
ta-analysis are shown in Table 1.
The global prevalence of H. pylori infection in pregnant
women was calculated to be 46% (95% CI: 38 to 54). The
lowest and the highest prevalence of the infection was in
Finland in 2000 (7.6%) and Sudan in 2012 (94%), respec-
tively (Figure 2).
The prevalence of H. pylori in pregnant women was an-
alyzed separately for each continent which is displayed as
GIS features in Figure 3. The lowest rate in pregnant wom-
en was reported to be among the Europeans 25% (95% CI:
9 to 40) and the highest prevalence in South America 62%
(95% CI: 53 to 71).
In the investigation of the prevalence of H. pylori in-
fection among pregnant women in the world in terms of
diagnostic criteria (serology, urea breath test, stool anti-
gen or PCR) the confidence intervals intersect each other
which is not statistically significant (Figure 4).
Discussion
In the recent studies, it has proven that H. pylori not only
causes digestive diseases but also may be associated with
diseases related to insufficient absorption of nutrients
such as cardiovascular disease, anemia, low birthweight,
anemia and headache (3,33).
The current study is the first systematic review and me-
ta-analysis study on the worldwide prevalence of H. pylori
infection during pregnancy. In this study, the prevalence
of H. pylori infection in pregnant women was estimat-
ed at 46%. The range of the prevalence of the infection
31
Azami et al

Table 1. The Details of the Studies Entered Into the Meta-analysis

Sample Mean Age Diagnostic Prevalence of

Author Name Country Continent Year
Size (Mean ± SD) Criteria Helicobacter pylori (%)
Weyermann et al (4) Germany Europe 2001 898 30.7±5.2 UBT 22.9
Fukui et al (8) Japan Asia 2003 120 Serology 24.2
Poveda et al (9) Chile South America 2005 274 Serology 68.6
Farag et al (16) Tanzania Africa 2004 857 28.1±7.1 UBT 17.5
Baingana et al (17) Uganda Africa 2008 447 Stool-Ag 45.2
Shirin et al (18) Israel Asia 2004 185 Serology 45.9
Epstein et al (19) USA America 2012 82 Serology 43.9
Karaer et al (20) Turkey Asia 2007 296 Serology 56.8
Kenna et al (21) United Kingdom America 2003 404 Serology 41.8
Alvarado-Esquivel (22) Mexico South America 2008 343 24.2±5.9 Serology 52.2
Mulayim et al (23) Turkey Asia 2006 117 UBT 61.5
Laiho et al (24) Finland Europe 2000 772 Serology 7.6
Ugwuja and Akubugwo (25) Nigeria Africa 2008 349 27.04±4.8 Serology 24.1
Bromberg et al (26) USA America 2006 37 29.6±5 Serology 73
Baingana et al (27) Uganda Africa 2014 151 Serology 70
Santos et al (28) Mexico South America 2006 71 Serology 59.2
Mubarak et al (29) Sudan Africa 2012 179 Serology 94
Hollander et al (30) Netherlands Europe 2010 6837 29.7±5.3 Serology 46
Cardaropoli et al (31) Italy Europe 2010 2820 32.2±4.5 Serology 28.5
Kitagawa et al (6) Japan Asia 2001 1588 PCR 29.2
Seiskari et al (7) Finland Europe 2001 243 Serology 19
Karen (32) Mexico South America 2000 383 Serology 56
Karen (32) Mexico South America 2000 368 Serology 74
Abbasalizadeh (5) Iran Asia 2001-13 1605 Serology 45.9

Figure 1. The Flowchart Stages of Entering the Articles Into Meta-analysis.

32 International Journal of Women’s Health and Reproduction Sciences, Vol. 5, No. 1, January 2017
Azami et al

%
Study ES (95% CI) Weight

2
1 0.23 (0.20, 0.26) 4.25
12 0.08 (0.06, 0.10) 4.26
18 0.46 (0.45, 0.47) 4.27
19 0.28 (0.27, 0.30) 4.26
21 0.19 (0.14, 0.24) 4.20
Subtotal (I^2 = 99.69%, p = 0.00) 0.25 (0.09, 0.40) 21.24

1
2 0.24 (0.17, 0.33) 4.12
6 0.45 (0.38, 0.53) 4.13
8 0.57 (0.51, 0.62) 4.18
11 0.61 (0.51, 0.70) 4.07
20 0.29 (0.27, 0.31) 4.26
24 0.46 (0.43, 0.48) 4.25
Subtotal (I^2 = 97.27%, p = 0.00) 0.44 (0.33, 0.54) 25.01

5
3 0.68 (0.62, 0.74) 4.19
10 0.52 (0.47, 0.58) 4.19
16 0.59 (0.47, 0.71) 3.94
22 0.56 (0.51, 0.61) 4.20
23 0.74 (0.69, 0.78) 4.22
Subtotal (I^2 = 92.10%, p = 0.00) 0.62 (0.53, 0.71) 20.74

3
4 0.17 (0.15, 0.20) 4.25
5 0.45 (0.41, 0.50) 4.21
13 0.24 (0.20, 0.29) 4.22
15 0.70 (0.62, 0.77) 4.13
17 0.94 (0.89, 0.97) 4.24
Subtotal (I^2 = 99.70%, p = 0.00) 0.50 (0.18, 0.82) 21.04

4
7 0.43 (0.32, 0.54) 3.98
9 0.42 (0.37, 0.47) 4.21
14 0.73 (0.56, 0.86) 3.77
Subtotal (I^2 = 88.05%, p = 0.00) 0.51 (0.35, 0.67) 11.96

Heterogeneity between groups: p = 0.001

Overall (I^2 = 99.34%, p = 0.00); 0.46 (0.38, 0.54) 100.00

-.5 0 .5 1 1.5

Figure2. Forest plots of the Global prevalence of Helicobacter Pylori infection in pregnant women for random
Figure 2. Forest Plots of meta-analyses
effects the Global Prevalence of Helicobacter
(Squares represent pyloriofInfection
effect estimates individualinstudies
Pregnant Women
with their for Random
95%confidence Effects
interval (CI)Meta-analyses
(Squares representofeffect
the prevalence
estimatesofofHelicobacter Pylori with
individual studies withthe size95%
their of squares proportional
CI of the prevalence to the weight assigned
of Helicobacter to thewith
pylori study
theinsize of squares
the meta-analysis.
proportional to the weight assigned toThe diamond
the study inrepresents the overall result
the meta-analysis. The and 95%CIrepresents
diamond of the random-effects
the overallmeta-analysis).
result and 95% CI of the random-
effects meta-analysis).

Figure 3. GIS of Global Prevalence of Helicobacter pylori Infection in Pregnant Women Based on Continent for Random Effects Meta-
analysis.

International Journal of Women’s Health and Reproduction Sciences, Vol. 5, No. 1, January 2017 33
Azami et al

Prevalence
%
Study ES (95% CI) Weight

UBT
Weyermann (2001) 0.23 (0.20, 0.26) 4.25
Farag (2004) 0.17 (0.15, 0.20) 4.25
Mulayim (2006) 0.61 (0.51, 0.70) 4.07
Subtotal (I^2 = 97.68%, p = 0.00) 0.33 (0.19, 0.46) 12.57

serology
Fukui (2003) 0.24 (0.17, 0.33) 4.12
Poveda (2005) 0.68 (0.62, 0.74) 4.19
Shirin (2004) 0.45 (0.38, 0.53) 4.13
Epstein (2012) 0.43 (0.32, 0.54) 3.98
Karaer (2007) 0.57 (0.51, 0.62) 4.18
Kenna (2003) 0.42 (0.37, 0.47) 4.21
Esquivel (2008) 0.52 (0.47, 0.58) 4.19
Laiho (2000) 0.08 (0.06, 0.10) 4.26
Ugwuja (2008) 0.24 (0.20, 0.29) 4.22
Bromberg (2006) 0.73 (0.56, 0.86) 3.77
Baingana (2014) 0.70 (0.62, 0.77) 4.13
Santos (2006) 0.59 (0.47, 0.71) 3.94
Mubarak (2012) 0.94 (0.89, 0.97) 4.24
Hollander (2010) 0.46 (0.45, 0.47) 4.27
Cardaropoli (2010) 0.28 (0.27, 0.30) 4.26
Seiskari (2001) 0.19 (0.14, 0.24) 4.20
Karen (2000) 0.56 (0.51, 0.61) 4.20
Karen (2000) 0.74 (0.69, 0.78) 4.22
Azami (2013) 0.46 (0.43, 0.48) 4.25
Subtotal (I^2 = 99.40%, p = 0.00) 0.49 (0.39, 0.59) 78.96

stool-Ag
Baingana (2008) 0.45 (0.41, 0.50) 4.21

PCR
Kitagawa (2001) 0.29 (0.27, 0.31) 4.26

Heterogeneity between groups: p = 0.000

Overall (I^2 = 99.34%, p = 0.00); 0.46 (0.38, 0.54) 100.00

.25 .5 .75 1

Figure 4. Forest Plots of the Global Prevalence of Helicobacter pylori Infection in Pregnant Women Based on a Diagnostic Method for
Figure4. Forest plots of the Global prevalence of Helicobacter Pylori infection in pregnant women based on a
Random Effects Meta-analyses.
diagnostic method for random effects meta-analyses.

in different studies was highly variable which have been
reported between 8%-94%. The prevalence of this infec-
tion in pregnant women may reflect the prevalence among
the general population so that the prevalence of H. pylori
among pregnant women in the studies of Abbasalizadeh et
al in Iran and Goodman et al in Mexico is estimated to be
similar to the general population (5,32).
The prevalence of H. pylori infection among pregnant
women varies based on their social and economic status
and hygiene status. Even the diagnostic methods are dif-
ferent according to the mentioned differences, for exam-
ple the prevalence of this infection in pregnant women in
Europe and Japan is calculated to be 20 to 30%, in Turkey,
Mexico, Texas and America 50% to 80%, in Egypt and
Gambia is above 80% (15). In this study, the prevalence
of infection in pregnant women was estimated separately
for the 5 continents as follows Europe (25%), Asia (44%),
Africa (50%), America (51%) and South America (62%).
What is clear from the results, the prevalence of these in-
fections is higher in developing countries such as South
America countries compared to developed countries such
as European countries, which is also shown in the study of
Bures et al (33).
The prevalence of this infection has been reduced in a
lot of countries, for instance, in previous studies the prev-
alence of the infection in Iran, France and Finland has
been reported 85%, 21.5% and 31%, respectively (7,34)
that can be consistent with better health and improvement
of infrastructure in the countries which led to reduction of
infection diseases while the prevalence of the mentioned
diseases is still high in African and South American
countries (15).
Diagnosis of H. pylori infection includes 1) invasive
techniques (requiring endoscopy) such as rapid urease
test, culture, and histology, and 2) non-invasive methods
such as serology, urea breath test (UBT) and stool antigen
test (33). Invasive methods due to ethical issues and UBT
because of the use of radioactive materials, are prohibit-
10
ed in pregnancy (35). Invasive methods due to ethical is-
sues and UBT due to the use of radioactive materials are
prohibited in pregnancy (35). In most of the studies that
investigated the prevalence of H. pylori among pregnant
women (80%) based on diagnostic method, serology was
the dominant method and this amount was measured to
be 49% which had a slight difference with general estima-
tion. While the mentioned prevalence has been obtained
lesser through other diagnostic methods, for example, the
prevalence based on UBT and stool antigen methods was
measured 33% and 29%. The most obvious reason for a
lower prevalence of H. pylori, in this rate, can be the low
number of studies for UBT and stool antigen methods. On
the other side this method rep-resents the rate of current
infection while in serology method beside current infec-
tion, the previous infection will be also positive.
Conclusion
This meta-analysis shows that about half of pregnant
women worldwide are infected with H. pylori and the

34 International Journal of Women’s Health and Reproduction Sciences, Vol. 5, No. 1, January 2017
Azami et al
prevalence of this infection in the continent of South
America and Africa is far more than other continents. It is
suggested that, in order to control H. pylori in this high-
risk group, a constant check of the H. pylori infection in
pregnancy, appropriate hygienic facilities and improve-
ment of education levels in women of gestational age take
to an action.
Ethical Issues
The study was approved by the Women’s Reproductive
Health Research Center Ethical Review Committee as
number IR.TBZMED.REC.1395.508.
Conflict of Interests
All authors declare that there is no conflict of interest.
Financial Support
Women’s Reproductive Health Research Centre of the Ta-
briz University of Medical Science.
Acknowledgments
We would like to thank Women’s Reproductive Health Re-
search Centre of the Tabriz University of Medical Science
for supporting this study.
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1- exp Helicobacter Pylori /
2- exp Helicobacter Infection/
3- exp Pregnant Women/
4- exp Pregnancy/
5- exp Pregnancy Complications/
6- exp Gestational/
7- exp Prevalence/
8- exp Epidemiology/
9- exp Iran
10- 7 or 8 or 9
11- 1/2/4/5/6 and 10
12- * Helicobacter pylori /exp [Prevalence]
13- 10 or 12
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Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
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