Institute for Biomedical Informatics and Division of Biomedical Informatics, College of Medicine, University of Kentucky, Lexington, KY (Drs Hammerslag and Talbert).
AcademyHealth, Washington, DC (Mses Campbell-Baier, Otter, and Kennedy).
Am J Obstet Gynecol MFM. 2023 Jun;5(6):100937. doi: 10.1016/j.ajogmf.2023.100937. Epub 2023 Mar 17.
Congenital syphilis can cause severe morbidity, including miscarriage and stillbirth, and rates are increasing rapidly within the United States. However, congenital syphilis can be prevented with early detection and treatment of syphilis during pregnancy. Current screening recommendations propose that all women should be screened early in pregnancy, whereas women with elevated risks for 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.
This study aimed to examine associations between the odds of prenatal syphilis screening and sexually transmitted infection history or other patient characteristics across 3 states with elevated rates of congenital syphilis.
We used the Medicaid claims data from Kentucky, Louisiana, and South Carolina for 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 health history, demographic factors, and Medicaid enrollment history. Patient history was established using a 4-year lookback period of the Medicaid claims data; in state A, sexually transmitted infection surveillance data were used to improve the sexually transmitted infection history.
The prenatal syphilis screening rates varied by state, ranging from 62.8% to 85.1% of deliveries to women without a recent history of sexually transmitted infections and from 78.1% to 91.1% of deliveries to women with a previous sexually transmitted infection. For the main outcome of syphilis screening at any time during pregnancy, deliveries associated with previous sexually transmitted infections had 1.09 to 1.37 times higher adjusted odds ratios of undergoing screening. Deliveries to women with continuous Medicaid coverage throughout the first trimester also had higher odds of syphilis screening at any time (adjusted odds ratio, 2.45-3.15). Among deliveries to women with a previous sexually transmitted infection, only 53.6% to 63.6% underwent first-trimester screening and this rate was still just 55.0% to 69.5% when considering only deliveries to women with a previous sexually transmitted infection and full first-trimester Medicaid coverage. Fewer delivering women underwent third-trimester screening (20.3%-55.8% of women with previous sexually transmitted infection). Compared with deliveries to White women, deliveries to Black women had lower odds of first-trimester screening (adjusted odds ratio, 0.85 in all states) but higher odds of third-trimester screening (adjusted odds ratio, 1.23-2.03), potentially impacting maternal and birth outcomes. For state A, linkage to surveillance data doubled the rate of detection of a previous sexually transmitted infection because 53.0% of deliveries by women with a previous sexually transmitted infection would not have had sexually transmitted infection history detected using Medicaid claims alone.
A previous sexually transmitted infection and continuous preconception Medicaid enrollment were associated with higher rates of syphilis screening, but Medicaid claims alone do not fully capture the sexually transmitted infection history of patients. The overall screening rates were lower than would be expected given that all women should undergo prenatal screening, but the rates in the third trimester were particularly low. Of note, there are gaps in early screening for non-Hispanic Black women who had lower odds of first-trimester screening when compared with non-Hispanic White women despite being at elevated risk for syphilis.
先天性梅毒可导致严重的发病率，包括流产和死产，并且在美国，其发病率正在迅速上升。然而，通过早期检测和治疗妊娠期间的梅毒，可以预防先天性梅毒。目前的筛查建议提出，所有妇女都应在妊娠早期进行筛查，而患有先天性梅毒高风险的妇女应在妊娠后期再次筛查。先天性梅毒发病率的迅速上升表明，产前梅毒筛查仍存在差距。
本研究旨在检查在美国三个先天性梅毒发病率较高的州，孕妇梅毒筛查的可能性与性传播感染史或其他患者特征之间的关系。
我们使用了肯塔基州、路易斯安那州和南卡罗来纳州的医疗补助（Medicaid）索赔数据，这些数据来自 2017 年至 2021 年的分娩妇女。在每个州，我们都检查了产前梅毒筛查的对数几率，作为母亲健康史、人口统计学因素和医疗补助登记史的函数。患者病史是通过 Medicaid 索赔数据的 4 年回溯期确定的；在 A 州，性传播感染监测数据被用来改善性传播感染史。
产前梅毒筛查率因州而异，从无近期性传播感染史的妇女的分娩中 62.8%到 85.1%，以及从有既往性传播感染史的妇女的分娩中 78.1%到 91.1%不等。对于在整个怀孕期间任何时候进行梅毒筛查的主要结局，有既往性传播感染史的分娩者进行筛查的调整后优势比为 1.09 到 1.37 倍。在整个妊娠早期持续获得医疗补助的妇女的分娩者，任何时候进行梅毒筛查的几率也更高（调整后的优势比，2.45-3.15）。在有既往性传播感染史的分娩妇女中，只有 53.6%到 63.6%进行了妊娠早期筛查，当仅考虑有既往性传播感染史和整个妊娠早期获得医疗补助的分娩妇女时，这一比例仍为 55.0%至 69.5%。进行第三孕期筛查的分娩妇女较少（有既往性传播感染史的妇女中 20.3%至 55.8%）。与白人妇女相比，黑人妇女进行妊娠早期筛查的几率较低（所有州的调整优势比均为 0.85），但进行第三孕期筛查的几率较高（调整优势比为 1.23-2.03），这可能会影响母婴结局。对于 A 州，与监测数据的链接使既往性传播感染的检出率增加了一倍，因为在有既往性传播感染史的妇女中，有 53.0%的分娩者如果仅使用医疗补助索赔数据，将不会发现性传播感染史。
既往性传播感染和孕前持续获得医疗补助与梅毒筛查率较高有关，但仅使用医疗补助索赔数据并不能完全捕捉到患者的性传播感染史。总体筛查率低于预期，因为所有妇女都应进行产前筛查，但第三孕期的筛查率特别低。值得注意的是，非西班牙裔黑人妇女的早期筛查存在差距，尽管她们感染梅毒的风险较高，但与非西班牙裔白人妇女相比，她们在妊娠早期筛查的几率较低。
