Abstract
Background
Congenital syphilis can cause severe morbidity, including miscarriage and stillbirth,
and rates are increasing rapidly within the US. However, congenital syphilis can be
prevented with early detection and treatment of syphilis during pregnancy. Current
screening recommendations hold that all women should be screened early in pregnancy,
while women at elevated risk of congenital syphilis should be screened again later
in pregnancy. The rapid increase in congenital syphilis rates suggests that there
are still gaps in prenatal syphilis screening.
Objectives
To examine associations between the odds of prenatal syphilis screening and sexually
transmitted infection (STI) history or other patient characteristics, in three states
with elevated rates of congenital syphilis.
Study Design
We used Medicaid claims data from Kentucky, Louisiana, and South Carolina from women
with deliveries between 2017 and 2021. Within each state, we examined the log-odds
of prenatal syphilis screening as a function of the mother's patient health history,
demographic factors, and Medicaid enrollment history. Patient history was established
using a 4-year lookback of Medicaid claims data; in State A, STI surveillance data
was used to improve STI history.
Results
Prenatal syphilis screening rates varied by state, ranging from 62.8-85.1% for deliveries
by women without a recent history of STI and from 78.1-91.1% for deliveries by women
with prior STI. For the main outcome, syphilis screening at any time in pregnancy,
deliveries associated with prior STI had 1.09-1.37 times higher adjusted odds ratios
(aOR). Deliveries by women with continuous Medicaid throughout the first trimester
also had higher odds of syphilis screening at any time (aOR = 2.45-3.15). Among deliveries
by women with a prior STI, only 53.6-63.6% received first trimester screening and
this rate was still just 55.0-69.5% when considering only deliveries by women with
a prior STI and full first trimester Medicaid coverage. Fewer delivering women received
third trimester screening (20.3-55.8% of women with prior STI). Compared to deliveries
by White women, deliveries by Black women had lower odds of first trimester screening
(aOR = 0.85 in all states) but higher odds of third trimester screening (aOR = 1.23-2.03),
potentially impacting maternal and birth outcomes. For State A, linkage to surveillance
data doubled the rate of prior STI detection, as 53.0% of deliveries by women with
a prior STI would not have had STI history detected using Medicaid claims alone.
Conclusions
Prior STI and continuous pre-conception Medicaid enrollment were associated with higher
rates of syphilis screening, but Medicaid claims alone do not fully capture patient
STI history. Overall screening rates were lower than would be expected, given that
all women should undergo prenatal screening, but rates in the third trimester were
particularly low. Notably, there are gaps in early screening for non-Hispanic Black
women, who had lower odds of first trimester screening compared to non-Hispanic White
women despite being at elevated risk of syphilis.
Keywords
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Article info
Publication history
Accepted:
March 13,
2023
Received in revised form:
February 26,
2023
Received:
January 9,
2023
Publication stage
In Press Accepted ManuscriptIdentification
Copyright
© 2023 Elsevier Inc. All rights reserved.
