Objective
The objective of the study was to describe prenatal screening, positive test rates, and the administration of indicated interventions for hepatitis B, rubella, syphilis, group B streptococcus (GBS), chlamydia, and gonorrhea in the United States using 2 population-based surveys.
Study Design
Both surveys abstracted demographic, prenatal, and delivery data from a representative sample of delivering women in 10 states. Analyses accounted for the complex sampling design.
Results
Among the 7691 and 19,791 women in the 2 studies, screened proportions before delivery were more than 90% for hepatitis B and rubella, 80% for syphilis, 72-85% for GBS, and less than 80% for chlamydia and gonorrhea. Inadequate prenatal care was the strongest factor associated with no screening. Administration of interventions indicated by positive test results was variable but generally low.
Conclusion
Improved prenatal screening and administration of indicated treatments or interventions, particularly for syphilis, GBS, chlamydia, and gonorrhea, will further protect newborns from infection.
During pregnancy, maternal infection with chlamydia, gonorrhea, syphilis, hepatitis B virus (HBV), rubella, and colonization with group B streptococcus (GBS) contributes to maternal, fetal, neonatal, and later morbidity and mortality. For example, approximately 25% of infants who become chronically infected with hepatitis B die prematurely from cirrhosis or liver cancer (2000-4000 deaths/year), 20-60% of infants born to women with untreated chlamydial infection develop conjunctivitis or pneumonia, and untreated syphilis, depending on stage, affects 40% to virtually 100% of infants, 50% of which are preterm or stillborn.
Vertical transmission of all of these pathogens is preventable through appropriate prenatal screening and management of the mother and newborn. The Centers for Disease Control and Prevention (CDC), the American College of Obstetrics and Gynecology (ACOG), and the US Preventive Services Task Force (USPSTF) recommend routine, universal screening of all pregnant women for syphilis, chlamydia, HBV, and human immunodeficiency virus (HIV) as well as testing for rubella immunity. The CDC and ACOG also recommend screening all women for GBS and high-risk women for gonorrhea.
Recommended interventions include penicillin at least 30 days before delivery for syphilis, treatment during pregnancy for chlamydia and gonorrhea, administration of hepatitis B immunoglobulin, and vaccination for newborns born to HBV-positive women, postpartum maternal vaccination for rubella-susceptible women to protect future pregnancies, and intrapartum antibiotic prophylaxis for women colonized with GBS.
Many of these infections are known to disproportionately affect adults of certain racial and ethnic groups. The identification of groups of pregnant women at the highest risk for infection as well as the recognition of factors associated with lack of prenatal screening and treatment are critical for improving the success of prenatal prevention programs.
We used 2 large, multistate, population-based surveys of labor and delivery records in the United States to describe, by state, the proportion of delivering women in 2003 and 2004 who received prenatal screening for preventable infectious diseases, tested positive for specific infections, and received adequate interventions. Some of the results of GBS screening and prophylaxis have previously been presented. HIV screening results from these surveys will be presented in greater detail elsewhere. We also evaluated factors associated with lack of prenatal screening and maternal infection.
Materials and Methods
Survey design
Birthnet. Demographic, prenatal, and peripartum information was abstracted from 7691 US labor and delivery records from a random sample of 819,000 live births from 10 active surveillance sites ( Table 1 ) in 2003-2004. The sample was stratified by surveillance area, birth year, and hospital; all hospitals with at least 10 births per year were included. Within strata a random sample of births was selected using a systematic probability-proportional-to-size selection. Data were weighted based on the probability of chart selection and adjusted to account for nonresponse. Adjustments were made within each surveillance area and year so that the number of term and preterm births represented that of the overall population.
| State | Birthnet locales a | n | Birth cohort b | DHAP/RTI locales | n | Birth cohort b |
|---|---|---|---|---|---|---|
| California | 3 counties, Bay area | 679 | 81,741 | N/A | ||
| Colorado | 5 counties Denver | 630 | 81,741 | N/A | ||
| Connecticut | Entire | 861 | 82,505 | Entire | 2349 | 43,337 |
| District of Columbia | N/A | Entire | 1288 | 14,611 | ||
| Florida | N/A | Selected | 2083 | 104,518 | ||
| Georgia | 20 counties, Atlanta | 977 | 145,731 | Selected | 2397 | 64,885 |
| Maryland | Entire | 906 | 130,644 | Entire | 1643 | 70,067 |
| Michigan | N/A | Selected | 1971 | 67,327 | ||
| Minnesota | 7 counties | 727 | 78,298 | N/A | ||
| New Jersey | N/A | Entire | 1399 | 113,375 | ||
| New Mexico | 6 counties | 608 | 27,071 | N/A | ||
| New York | 7 counties, Rochester and 3 counties, Albany | 804 | 44,882 | N/A | ||
| Oregon | 3 counties | 622 | 40,356 | |||
| Pennsylvania | N/A | Selected | 1875 | 22,287 | ||
| South Carolina | N/A | Selected | 2405 | 41,017 | ||
| Tennessee | 11 urban counties | 877 | 110,089 | Selected | 2381 | 48,262 |
| Total | 10 states | 7,691 | 819,528 | 10 states | 19,791 | 589,686 |
a Birthnet areas accessed from http://www.cdc.gov/abcs/methodology/surv-pop.html (accessed Nov. 10, 2010);
Surveillance officers reviewed labor and delivery records for hepatitis B, rubella, syphilis, GBS, chlamydia, and gonorrhea testing data and on interventions for women testing positive. Because the neonatal chart was not abstracted, there is no information on administration of hepatitis B immune globulin and neonatal HBV vaccination.
Survey design
Division of HIV/AIDS Prevention (DHAP)/Research Triangle Institute (RTI). Births in 10 states with the highest rates of perinatal HIV transmission, high rates of pediatric AIDS, or state policies likely to have an impact on the rates of transmission were sampled using state vital records from calendar year 2003 ( Table 1 ). In smaller states (Connecticut, District of Columbia, Maryland, New Jersey) all hospitals were eligible for selection; in larger states only certain locales were chosen.
In each state or locale, up to 11 delivery hospitals were selected using a systematic probability-proportional-to-size selection; 109 hospitals were selected. Of these, 97 participated in the survey (89.0%), and 220 delivery records were selected using a simple random sample. In some states, large hospitals were selected twice (for a total of 440 births) because of the hospital selection design. Hospital staff or nonhospital abstractors abstracted medical records for prenatal and peripartum testing data for hepatitis B, rubella, syphilis, GBS, and chlamydia. Interventions for women testing positive were also abstracted except for women with chlamydia. Receipt of infant HBV vaccine was abstracted from the infant’s chart. The DHAP/RTI abstraction form was based on the Birthnet form for these infections.
Definitions
Race and ethnicity were abstracted from medical charts and may reflect self-identification as well as chart-abstractor or clinician interpretation. Because there were few American Indian/Alaska Native or Pacific Island women, they were combined in the “other” race category. Adequate testing for syphilis, gonorrhea, or chlamydia was defined as any test before the labor admission date because treatment should be provided before delivery (at least 30 days before delivery for syphilis) to reduce neonatal morbidity. A positive syphilis test was a positive rapid plasma reagin, so we were unable to assess who had active syphilis requiring treatment.
Adequate HBV and rubella testing was defined as a prenatal or antenatal test because intervention after delivery is still effective. Adequate testing for GBS was defined as a test at least 2 days before delivery because culture requires up to 48 hours, and effective intervention occurs during the intrapartum period.
Adequate therapy was defined as newborn vaccination against hepatitis B before discharge for women who had HepBsAg, maternal rubella vaccination before discharge for women who were rubella nonimmune or equivocal; maternal parenteral penicillin at least 4 weeks prior to delivery for syphilis; maternal intrapartum antibiotic receipt for GBS; maternal erythromycin, amoxicillin, or azithromycin for chlamydia; and maternal ceftriaxone, cefixime, or spectinomycin for gonorrhea.
Prenatal care was categorized into adequate, inadequate, or intermediate based on the Kessner/Institute of Medicine index ; the models adequate and intermediate were combined and compared with inadequate or no care. Preterm was defined as delivery at less than 37 weeks’ gestation.
Analysis
Sample weights were used in all analyses to account for the unequal probability of selection. SUDAAN (RTI International, Research Triangle Park, NC) was used to account for the stratified complex survey design; we present weighted proportions. Multivariable analyses were performed using all main effects that were found to be significant in bivariate analyses with P < .15. Final multivariable models included those effects that remained significant with a P < .05. A CDC institutional review board determined that these projects were program evaluations, and therefore, informed consent was not required. As appropriate, the local institutional review board at each participating site also reviewed the protocol and waived the requirement for informed consent.
Results
A total of 7691 labor and delivery records were abstracted for the Birthnet survey and 19,791 for the DHAP/RTI survey ( Table 1 ). In both surveys, the mean maternal age was 28 years ( Table 2 ). The preterm delivery rate among the women in the Birthnet project was 11.0% (95% confidence interval [CI], 10.0–12.1), whereas the rate was 16.2% (95% CI, 14.5–18.0%) in the DHAP/RTI survey. The populations were similar for many maternal and reproductive health characteristics ( Table 2 ).
| Maternal characteristics | Birthnet (n = 7691) | DHAP/RTI (n = 19,791) | ||
|---|---|---|---|---|
| Sample size | % (95% CI) | Sample size | % (95% CI) | |
| Age, y | ||||
| <20 | 752 | 8.7 (8.0–9.5) | 2242 | 9.8 (8.7–11.0) |
| ≥20 | 6873 | 91.3 (90.5–92.0) | 18,637 | 90.2 (89.0–91.3) |
| Race a | ||||
| White | 4441 | 56.0 (54.7–57.3) | 10,172 | 53.2 (46.7–59.6) |
| Black | 1302 | 19.6 (18.6–20.7) | 5510 | 24.3 (20.2–28.7) |
| Asian | 351 | 5.2 (4.7–5.9) | 540 | 2.9 (2.3–3.5) |
| Other/unknown | 1597 | 19.1 (18.2–20.1) | 3569 | 19.7 (15.0–25.4) |
| Ethnicity a | ||||
| Hispanic | 1478 | 18.0 (17.1–19.0) | 2851 | 18.3 (14.0–23.6) |
| Non-Hispanic | 6014 | 80.5 (79.5–81.5) | 8919 | 38.6 (32.1–45.5) |
| Unknown | 199 | 1.5 (1.2–1.9) | 8951 | 43.1 (36.1–50.4) |
| Prior preterm birth b | ||||
| Yes | 475 | 6.9 (6.2–7.7) | 1229 | 6.2 (5.4–7.0) |
| Illicit drug use c | ||||
| Yes | 260 | 3.2 (2.8–3.7) | N/A | |
| Labor and delivery payment d | ||||
| Medicaid | 2104 | 25.3 (24.2–26.4) | 6169 | 27.0 (23.5–30.8) |
| Other insurance | 4702 | 64.5 (63.3–65.7) | 11,516 | 63.2 (58.6–67.6) |
| Other, self-pay | 805 | 10.2 (9.5–11.0) | 2164 | 9.9 (7.2–13.4) |
| Kessner index of prenatal care e | ||||
| Adequate (first Δ) | 4057 | 58.5 (57.1–59.9) | 9335 | 48.1 (45.0–51.3) |
| Intermediate (second Δ) | 2193 | 31.6 (31.3–32.9) | 5331 | 28.5 (26.5–30.5) |
| None or inadequate f | 661 | 9.9 (9.1–10.8) | 4496 | 23.1 (19.9–27.3) |
| Missing | 780 | 629 | ||
| Prenatal visits | ||||
| Mean number | 7691 | 9.9 (9.8–10.0) | 16,608 | 9.8 (9.6–10.0) |
| Method of delivery | ||||
| Cesarean | 2037 | 25.5 (24.3–26.8) | 5918 | 32.0 (30.6–33.5) |
| Vaginal | 5654 | 13,513 | ||
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