Obstetrics and Gynecology International Table 1: Adverse pregnancy outcomes due to maternal syphilis. Harmon [4] (N = 1001) 17% 23% 21% 61% Ingraham [5] (N = 302) 22% 12% 33% 67% Rabut [6] (N = 722) 36% 36% 46% 35% 81% Watson-Jones [8, 11] 95%∗ 73% 49% Schulz [12] 100% — 65% 25% 25% 49% WHO [13] 100% — 75% 2 Outcome Stillbirth Neonatal Death Prematurity or low birth weight Infected Infant Any adverse outcome = Data not assessed. substantial proportions (40–81 percent) of syphilis-exposed fetuses are severely aﬀected, with stillbirth neonatal death being the most signiﬁcant consequences (Table 1) [4–8]. A smaller but substantial proportion of untreated maternal infections results in congenital infection in newborn infants, often manifested by premature birth, low birth weight, and failure to thrive. Among surviving infants, visceral involvement is common, as are fever, rashes, blindness, and a variety of typical skeletal and dental abnormalities [1]. The World Health Organization (WHO) estimates that globally the majority of maternal syphilis infections are untreated and of suﬃciently high-titer (RPR ≥ 1 : 8) to cause signiﬁcant fetal exposure to T. pallidum. This situation results in an estimated 692,100 to 1.53 million adverse pregnancy outcomes each year caused by syphilis (Table 2) [8, 11–13]. Approximately 650,000 of these pregnancy complications result in perinatal deaths (i.e., deaths occurring from 22 weeks gestation through the ﬁrst 7 days of life). Thus, untreated maternal syphilis is believed to have at least similar mortality, if not higher, than other important infections during pregnancy such as HIV (estimated to cause 250,000– 290,000 perinatal deaths globally) [14] neonatal tetanus (200,000 perinatal deaths), or malaria in pregnancy (200,000 perinatal deaths) [13]. Globally, untreated maternal syphilis infection accounts for up to one quarter of all stillbirths and 11% of neonatal deaths, with most of these perinatal deaths occurring in developing settings with moderate or high antenatal syphilis prevalence and weak health systems [15]. 3. Situation: Health Services Delivery Now Adverse pregnancy outcomes caused by syphilis can be almost entirely averted through early identiﬁcation of mater- nal infections through antenatal screening programmes, and prompt treatment of women with positive tests with a single dose of long acting penicillin prior to 24 weeks gestation [16]. Maternal syphilis screening and treatment are recognized as part of essential antenatal services [17], and almost all nations already have existing policies recommending universal syphilis screening during pregnancy [18]. However, implementation of the policy is weak in many settings, particularly in countries with highest disease burden. High-burden countries have reported numerous barriers that limit eﬀective screening and treatment as part of basic antenatal health services [19]. Access to early antenatal clin- ical (ANC) services, especially prior to 24 weeks gestation, McDermott [7] (N = 436) Watson-Jones [8] (N = 100) Table 2: Estimated global burden of congenital syphilis cases. Proportion of seropositive women with: Untreated syphilis High serologic titer (≥1 : 8) Adverse pregnancy outcome due to syphilis∗∗ Global Annual No. of Congenital Syphilis Cases 692,100 1,323,900 1,527,600 Note that all assumptions based on WHO estimate of 2,036,753 pregnant women with syphilis [9]. ∗not included in the original Watson-Jones model; ∗∗includes late fetal loss, perinatal death, prematurity/low birth weight, neonatal infection. is still limited in many parts of the world, and particularly in sub-Saharan African nations where a third of women either receive care later in pregnancy or do not receive care at all [17]. Health providers, particularly those in lower- level health facilities, may be unaware of the burden of congenital syphilis or the need to identify and treat early in pregnancy, and thus may not prioritize syphilis screening for the ﬁrst antenatal visit. Syphilis diagnosis can be complicated and usually requires serologic screening with nontreponemal (e.g., RPR) or treponemal (e.g., TPHA) tests, and ideally both. While RPR tests, measuring active infection, are rela- tively simple and inexpensive, they require basic laboratory capacity, trained technical staﬀ, and ongoing quality control systems. Unfortunately many lower-level facilities providing antenatal services have no laboratory access, thus testing is often simply not done at all. In antenatal facilities with access to laboratories able to conduct RPR tests (typically district level or higher facilities), women must often go to a separate site for testing, incurring additional transportation costs and waiting time above the basic antenatal visit. Additionally, women are often asked to pay for the tests themselves, a substantial barrier for many women [17, 20–23]. Even in places that could feasibly provide testing rou- tinely, further systems level issues such as stockouts of critical commodities and inadequate numbers or distribution of clinical or laboratory providers can limit testing. Also, for women with positive tests, treatment can be delayed when results are not provided in a timely fashion, or