Syphilis In Pregnancy: A Health Systems Intervention Trial (SYTRUST trial)

Click here to open protocol as a pdf file.  The file will open in Acrobat Reader.


Sexually transmitted disease (STD) in pregnancy is a reproductive health issue of major importance in South Africa and the rest of the developing world. STDs pose a significant risk to both the pregnant woman and her fetus. Antenatal clinics, where women of reproductive age frequently seek care, may have a critical role to play in the prevention and treatment of these illnesses.

Screening for syphilis, a major cause of preventable pregnancy loss, is an important but frequently neglected component of antenatal care. About 40% of pregnant women with syphilis experience miscarriage, stillbirth or perinatal death if untreated. Appropriate care for syphilis consists of diagnosis, treatment, partner notification and related health education. Due to poor functioning of the health infrastructure in some places this does not always occur. We have shown that in Hlabisa more than 90% of pregnant women book for antenatal care. Although all women are screened for syphilis (prevalence 7-10%), in a recent study in a mobile antenatal clinic in Hlabisa only 49% were fully treated, largely because many women did not return to the clinic for their results. Unnecessary mortality attributable to syphilis (estimated at 27% of the district-wide perinatal mortality) is the result, despite high antenatal coverage and screening of all women.

This failure of service delivery is potentially remediable through on-site screening for syphilis with immediate treatment. Combined with improved health promotion and partner notification strategies, this approach would also offer a more comprehensive reproductive health approach to syphilis control, and it also could strengthen the capacity of the health system to begin to address other STDs in pregnancy. A pilot study of on-site testing in the mobile clinic referred to above  showed that the proportion of women adequately treated increased from 49% to 75% (p=0.004), and the perinatal mortality among women with syphilis was lower following on-site testing (6.8% vs 12%); due to the small sample size in this pilot study this reduction was not statistically significant (p=0.7).

This project will determine the feasibility, accuracy, and cost-effectiveness of on-site testing for syphilis in the community clinics of a rural South African health district. Impact will be measured through the key outcome measure, perinatal mortality, as well as process measures that include the proportion of women screened and treated, and the proportion of partners treated. The study design will be a clinic randomised trial. The study has the power to show a 50% reduction in mortality attributable to syphilis and a minimum reduction in total district perinatal mortality of 13.5%.

Click here to open protocol as a pdf file.  The file will open in Acrobat Reader.

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This page was last updated on 4th June 2004.