Sexually transmitted diseases are known to cause significant morbidity to infected patients, especially women. Many of these diseases pose a significant risk to the fetus and neonate of infected obstetric patients. Congenital infection with syphilis is common in affected mothers and can lead to a variety of birth defects or even neonatal death. Given that both the severity of illness and success of treatment in the neonate depends largely on the timing and adequacy of maternal identification and treatment, early and appropriate maternal screening is key in minimizing the transplacental or direct-contact transmission of disease.

Other, more common infections likewise represent a potential source of significant neonatal morbidity. It has been well established that untreated maternal chlamydia or gonorrhea infection at time of delivery frequently leads to neonatal infection in the form of a severe conjunctivitis, pneumonia, or neonatal sepsis. HIV infection carries with it significant potential for mortality, long-term morbidity, and social cost if not diagnosed in pregnancy. Early intervention in pregnancy can lower vertical transmission dramatically.

The American Congress of Obstetricians and Gynecologists (ACOG) recommends screening for each of these infections during the antenatal period. In the Guidelines for Perinatal Care , ACOG endorses screening for syphilis, chlamydia, hepatitis B virus, and HIV in the first trimester, followed by rescreening in the third trimester for chlamydia, HIV, and syphilis for “high-risk” populations. Some factors that are deemed “high-risk” include low socioeconomic status, age less than 25 years, African-American race, early age at coitarche, and both current and lifetime number of sexual partners. In a strong public health push, many states have reinforced these suggestions with legal mandates. In the state of North Carolina, prenatal care providers are required to test for syphilis, gonorrhea, and chlamydia at a woman’s first prenatal visit, and to retest for syphilis in the third trimester and again at time of delivery; those women less than 25 years of age or who are deemed to be at “high-risk” for gonorrhea or chlamydia should be retested in the third trimester or at delivery. Patients are also required to be tested for hepatitis B virus at the first visit, unless they are known to be positive for the virus at time of initial prenatal testing. In addition, the state of North Carolina requires that each obstetric patient be screened for HIV at the first prenatal visit and in the third trimester unless she specifically refuses testing. North Carolina law further stipulates that at time of delivery a patient be tested for HIV regardless of consent if the maternal HIV status is not known. Thus, to comply with these state mandated testing regimens, prenatal care providers are required to screen for 5 potential sexually transmitted infections (STIs) in the first trimester, 2 STIs in the third trimester, 1 at time of delivery, and potentially 2 more in the third trimester in “at risk” individuals.

The onus thus falls on the shoulders of the practitioner providing prenatal care to comply with these mandates. In a survey of prenatal care providers across the state, Troccolli et al found that the majority of providers recommended testing to all obstetric patients, but did discover that the level of encouragement was related to the practitioner’s perceived patient risk. However, in a survey given to patients across the country, approximately 30% of women surveyed reported that they had not been offered testing for HIV during their pregnancy. Another study that evaluated prenatal screening compliance for both HIV and syphilis in commercially insured patients in 1999 revealed that less than two-thirds of patients were screened for syphilis and only one-third for HIV. Similarly, routine annual screening for chlamydia is recommended for all sexually active women 25 years of age and younger. However, data from the Healthcare Effectiveness Data and Information Set (HEDIS) from 2000-2008 reveal that less than 60% of Medicaid and less than 50% of commercially insured patients were tested; by 2008 in North Carolina, less than 37% of women in this age bracket were screened. As the HEDIS data and Troccolli study suggest, perhaps some of these discrepancies in STI screening are based on risk stratification at the level of the individual provider. This then poses the question of whether compliance with recommended and mandated screening algorithms is greater in practices that deal with more at-risk populations. If such a difference were to be found, that information could then be used for process improvement at the level of the specific practices in question, but also could be extrapolated to other practices with similar patient populations.