Congenital Syphilis in Texas Section 6 - Barriers to Care

Texas uses internal and external case review boards to thoroughly examine probable and confirmed CS cases and syphilitic stillbirths, and review missed opportunities for CS prevention. DIS face challenges as they work to prevent maternal syphilis, such as delays in receiving a positive lab result or initiating partner services; there may be difficulty locating the client or their partner, leading to untreated syphilis cases or potential re-infection. Clients may experience housing instability, domestic or intimate partner violence, mental health issues, and/or substance use/abuse disorders that create competing priorities for seeking healthcare. Review boards have also found that women who deliver infants diagnosed with CS often have prior involvement with corrections (local, state, and federal jails or prisons) and/or child protective services. Transportation issues are frequently cited as a reason why a client could not make medical appointments. Clients report that late prenatal care is due to delays with Medicaid enrollment and difficulty finding a provider in their area. Additionally, Texas’ surveillance data has shown that even when clients are in prenatal care, not all clients received the third trimester test which has been Texas law since September 1, 2015.
 

Maternal Risk History

The maternal risk history provides insight into challenges faced by women who deliver infants with CS. Not all women who delivered an infant with CS have risk information available. Of the 222 women for whom this information was available, more than a third had a previous STD and one in seven had been incarcerated or had a history of substance use.

Figure 13: Risk History of Women Delivering an Infant with CS, Texas 2018*
 
* Women delivering an infant with CS who received a partner services interview within three years prior to birth

Prenatal Care

Among all women giving birth in Texas, only three percent did not receive prenatal care. [6] For women who gave birth to an infant with CS in 2018, the picture is very different. While three-quarters had some prenatal care, about one in four had no or unknown prenatal care. Among women with prenatal care, three out of five started care in their first trimester.

Figure 14: Prenatal care in mothers who delivered an infant with CS, Texas 2018 

Timing of Maternal Syphilis Diagnosis in Relation to Delivery

Timing of maternal syphilis diagnosis is critical for the initiation of timely treatment. A syphilis diagnosis at least 45 days prior to delivery allows enough time for providers and health departments to receive positive lab results and initiate adequate maternal treatment at least 30 days prior to delivery. In 2018, one-third of mothers were diagnosed with syphilis fewer than 45 days prior to delivery (Table 2).

Table 2: Timing of Maternal Syphilis Diagnosis Among Mothers Delivering an Infant with CS, Texas 2018

Maternal Treatment for Syphilis

For treatment among women delivering an infant diagnosed with CS, more than three in five had inadequate syphilis treatment (adequate treatment initiated less than 30 days prior to delivery, inadequate treatment for the diagnosed surveillance stage, or were untreated). Fewer than one in six had adequate syphilis treatment (treatment initiated =30 days prior to delivery with appropriate treatment based on syphilis stage) (Figure 15). For mothers diagnosed =45 days prior to delivery, the majority (63 percent) had inadequate treatment while only about one-quarter (24 percent) had adequate treatment (Figure 16).

Figure 15: Maternal Syphilis Treatment for Women Delivering an Infant with CS, Texas 2018

Figure 16: Maternal Syphilis Treatment for Women Delivering an Infant with CS who were diagnosed at least 45 days before delivery, Texas 2018

Note 6. Texas Department of State Health Services. Centers for Health Statistics. 2018 Provisional Texas Birth Certificate data.

Congenital Syphilis in Texas

Table of Contents | Executive Summary | About this Report | Understanding Syphilis | An Overview of Congenital Syphilis and Syphilis in Women of Childbearing Age in Texas | Maternal Demographics for Women Delivering Infants with Congenital Syphilis | Barriers to Care | Birth Outcomes Associated with Congenital Syphilis | Congenital Syphilis Cascade