Screening and treatment of sexually transmitted infections to improve health and birth outcomes among pregnant women in Botswana

Abstract

Chlamydia (C.) trachomatis and Neisseria (N.) gonorrhoeae infections in pregnancy are associated with adverse birth and neonatal outcomes. Despite this, diagnostic screening for these STIs is not routinely performed during pregnancy in most low- and middle-income countries (LMICs), including Botswana. The syndromic management approach, which relies on symptom-based diagnosis and pre-defined treatment protocols, is the standard-of-care in these settings. Further implementation and operational research is needed to inform the replacement of syndromic management with diagnostic screening in Botswana and other LMICs.

In this thesis, I used data collected during the Maduo Study, a non-randomised cluster-controlled trial conducted in Gaborone, Botswana between 2021 and 2022, to explore the impact of diagnostic C. trachomatis and N. gonorrhoeae screening in pregnancy on health outcomes among women and infants. I used a multiple-method approach including analysis of quantitative data collected from pregnant women, qualitative interviews with healthcare workers and cost-effectiveness analysis, and compared outcomes between intervention arm participants who received STI screening during pregnancy to standard-of-care (control) participants who received syndromic management.

There was a high burden of C. trachomatis (23%) and a low burden of N. gonorrhoeae infection (1%) among asymptomatic pregnant women in Botswana screened at their first antenatal care visit. Among women who tested positive and were re-tested approximately four weeks after treatment, 100% were cured. Prevalence of C. trachomatis postdelivery was significantly lower among women who received diagnostic antenatal screening during pregnancy compared to women who received the standard-of-care. More than one-third of women who had an STI infection postdelivery transmitted the infection to their infants. Healthcare providers supported the idea of diagnostic STI screening during pregnancy to identify specific infections and avoid missed diagnoses. Providers also noted several barriers that need to be considered prior to roll-out of STI screening including staffing and resource constraints. While costs were high, screening for C. trachomatis and N. gonorrhoeae was projected to be cost-effective for prevention of preterm or low birth weight outcomes among asymptomatic pregnant women, compared to syndromic management.

Together these findings offer critical insights that can contribute to decision-making at both national and regional levels regarding the implementation of C. trachomatis and N. gonorrhoeae screening during pregnancy in resource-constrained settings.