Gaps in the congenital syphilis prevention cascade: qualitative findings from Kern County, California

Abstract

Background Congenital syphilis is preventable through timely access to prenatal care, syphilis screening and treatment of pregnant women diagnosed as infected. In 2018, California had the second highest number of congenital syphilis cases in the United States (U.S.), a nearly twofold increase in cases since 2014. This study assessed gaps in preventing congenital syphilis in the high morbidity region of Kern County, California. Methods Between May 2018 and January 2019, we conducted five focus group discussions with pregnant/postpartum women and ten semi-structured interviews with prenatal care providers in Kern County. Focus group and interview data were recorded, transcribed, and analyzed to identify emergent themes pertaining to facilitators and barriers at each step (prenatal care, syphilis screening and treatment) in the congenital syphilis prevention cascade. Results Gaps in congenital syphilis prevention discussed in focus group discussions with pregnant/postpartum women were related to limited prenatal care access, social-, economic-, and cultural-barriers, and substance use and co-occurring intimate partner/domestic violence. The gaps identified from interviews with prenatal care providers included social economic vulnerabilities of pregnant women and stigma and shame around the vulnerabilities, distrust in medical system, prenatal substance use, limited prenatal substance use disorder treatment facilities, and inadequate provider training on context-specific congenital syphilis management strategies. Gaps in partner notification, screening and treatment for syphilis were brought up by pregnant/postpartum women and prenatal care providers. Conclusions Congenital syphilis continues to increase in Kern County and throughout the U.S. In high syphilis morbidity areas, comprehensive and tailored public health approaches addressing setting-specific gaps in prenatal screening and treatment are needed.

Congenital Syphilis Epidemiology, Prevention, and Management in the United States: A 2022 Update

“…This was followed by a lack of timely prenatal care in 28% and late identification of seroconversions in 11% [14]. Entry gaps to prenatal healthcare, retention gaps between prenatal visits, syphilis testing, and treatment appointments are obstacles to care, especially in at-risk populations struggling with poverty or substance use [16]. Persons who use substances of abuse during pregnancy may also avoid prenatal healthcare due to fear of judgment and legal consequences from healthcare providers, further increasing the risk of delayed diagnosis and missed or delayed treatment for this particularly vulnerable group [16].…”

“…Entry gaps to prenatal healthcare, retention gaps between prenatal visits, syphilis testing, and treatment appointments are obstacles to care, especially in at-risk populations struggling with poverty or substance use [16]. Persons who use substances of abuse during pregnancy may also avoid prenatal healthcare due to fear of judgment and legal consequences from healthcare providers, further increasing the risk of delayed diagnosis and missed or delayed treatment for this particularly vulnerable group [16]. Methamphetamine and heroin use have been identified as risk factors [1] for acquiring syphilis during pregnancy and may partially explain the high concentration of CS cases in the Southwestern US [17].…”

“…For example, focus groups with pregnant women and semi-structured interviews with prenatal care providers on the gaps in CS prevention in Kern County, California, found that underserved pregnant people experienced disproportionate challenges in access to care, and social, economic, and cultural barriers significantly impacted patient retention. Thus, it is imperative that prenatal care providers are trained to identify at-risk individuals and that clinics and hospitals are supported with resources to maintain patient follow-up and continued care [16].…”

New trends in congenital syphilis: epidemiology, testing in pregnancy, and management

“…Two qualitative studies from the United States identified key socioeconomic barriers to accessing care such as stigma and shame around social vulnerabilities, lack of education, distrust of healthcare systems, substance abuse and inadequate provider training. Public health policies need to be tailored to address these issues [29 ▪ ,30].…”

Educational intervention improves knowledge and adherence to treatment amongst puerperal women with syphilis: randomized clinical trial

“…4 Gaps in prevention efforts relate to limited access to prenatal care, social and psychological barriers, cultural factors, substance use, and domestic or intimate partner violence. 8 Addressing these challenges requires implementing personalized public health interventions and healthcare strategies to control and eliminate syphilis infection. These interventions aim to bridge gaps, provide targeted interventions, and ensure comprehensive care to prevent and address the spread of syphilis.…”