Prevention of Standards

for Maternal and

mother-to-child Neonatal Care
transmission of syphilis
INTEGRATED MANAGEMENT OF PREGNANCY AND CHILDBIRTH (IMPAC)

The standard
••ȱ™›Ž—Š—ȱ ˜–Ž—ȱœ‘˜ž•ȱ‹ŽȱœŒ›ŽŽ—Žȱ˜›ȱœ¢™‘’•’œȱŠȱ‘Žȱꛜȱ
Š—Ž—ŠŠ•ȱŸ’œ’ȱ ’‘’—ȱ‘Žȱꛜȱ›’–ŽœŽ›ȱŠ—ȱŠŠ’—ȱ’—ȱ•ŠŽȱ™›Ž—Š—Œ¢ǯȱ
At delivery, women who for some reason do not have test results
should be tested/retested. Women testing positive should be treated
and informed of the importance of being tested for HIV infection. Their
partners should also be treated and plans should be made to treat their
infants at birth.

Aim
To reduce maternal morbidity, fetal loss and neonatal mortality and
morbidity due to syphilis.

Requirements
A national policy and locally adapted guidelines on syphilis prevention,
management and care in pregnant women are available and are correctly
implemented.
All women have access to care during pregnancy, childbirth and the postpartum
period.
Health care providers are competent in syphilis prevention, screening during
pregnancy, treatment of seropositive pregnant women and their partners,
prophylaxis and treatment in the newborn, counselling on STI prevention, and how
to prevent re-infection during pregnancy by promoting condom use.
One on-site screening method is available in antenatal care (ANC) clinics and
maternity wards.
Supplies for testing are available at both ANC and laboratory level.
Laboratory centres and facilities to ensure quality laboratory testing are available.
Penicillin is available in the ANC clinic, maternity ward and postnatal clinic.
World Health Organization

A functioning referral system ensures that pregnant women who are allergic to
penicillin can be referred for treatment to a higher level of care.
ȱ —ȱŽěŽŒ’ŸŽȱœ¢™‘’•’œȱ–˜—’˜›’—ȱŠ—ȱ’—˜›–Š’˜—ȱœ¢œŽ–ȱ’œȱŠŸŠ’•Š‹•Žȱ˜›ȱ™›Ž—Š—ȱ
women.
Health education activities are carried out to raise the awareness of individuals,
Š–’•’ŽœȱŠ—ȱŒ˜––ž—’’Žœȱ˜ȱ‘Žȱ’–™˜›Š—ŒŽȱ˜ȱŠĴŽ—’—ȱȱŒ•’—’ŒœȱŽŠ›•¢ȱ’—ȱ
pregnancy for syphilis prevention and treatment.
2006
Standards 1.3 Prevention of mother-to-child transmission of syphilis 2

Applying the standard

›˜Ÿ’Ž›œȱ˜ȱ–ŠŽ›—Š•ȱŠ—ȱ—Ž˜—ŠŠ•ȱ‘ŽŠ•‘ȱŒŠ›Žǰȱ’—ȱ™Š›’Œž•Š›ȱœ”’••ŽȱŠĴŽ—Š—œǰȱ–žœDZ

ȱ Œ›ŽŽ—ȱŠ••ȱ™›Ž—Š—ȱ ˜–Ž—ȱ˜›ȱœ¢™‘’•’œȱ ’‘ȱ˜—Ȭœ’Žȱȱ˜›ȱ˜‘Ž›ȱŠŸŠ’•Š‹•Žȱ›Š™’ȱŽœȱŠȱ‘Žȱꛜȱ
antenatal visit. Screening should be done preferably before 16 weeks of gestation to prevent
congenital infection, and again in the third trimester.
Review syphilis test results at subsequent visits and at time of delivery. If the woman was not
ŽœŽȱž›’—ȱ™›Ž—Š—Œ¢ǰȱœ¢™‘’•’œȱœŒ›ŽŽ—’—ȱœ‘˜ž•ȱ‹Žȱ˜ěŽ›ŽȱŠĞŽ›ȱŽ•’ŸŽ›¢ǯ
Treat all seroreactive women with benzathine benzylpenicillin at the recommended dosage
˜ȱŠȱ•ŽŠœȱŘǯŚȱ–’••’˜—ȱž—’œȱ’—›Š–žœŒž•Š›•¢ȱŠœȱŠȱœ’—•Žȱ˜œŽǰȱŠĞŽ›ȱ‘ŠŸ’—ȱŽ¡Œ•žŽȱŠ••Ž›¢ȱ˜ȱ
™Ž—’Œ’••’—ǯȱ—ȱ‘ŽȱŒŠœŽȱ˜ȱŠ••Ž›¢ȱ˜ȱ™Ž—’Œ’••’—ǰȱ‘ŽȱŠĴŽ—Š—ȱœ‘˜ž•ȱŽœŽ—œ’’£ŽȱŠ—ȱ›ŽŠȱ ’‘ȱ
penicillin if trained to do so, or refer the patient to a higher level of care.
Advise women who test positive that their partner(s) must also be treated with the same
›Ž’–Ž—ǰȱŠœȱ Ž••ȱŠœȱ‘Žȱ‹Š‹¢ȱŠœȱœ˜˜—ȱŠœȱ™˜œœ’‹•ŽȱŠĞŽ›ȱ‹’›‘ǯȱ
Advise women who test negative how to remain negative by promoting condom use during
pregnancy.
Test for syphilis all women with a history of adverse pregnancy outcome (abortion, stillbirth,
syphilitic infant, etc.) and treat accordingly.
Treat women with clinical disease or a history of exposure to a person with infectious syphilis.
Screen all women with syphilis for other STIs and HIV infection, and provide counselling and
treatment accordingly.
ȱ 쎛ȱŸ˜•ž—Š›¢ȱŒ˜ž—œŽ••’—ȱŠ—ȱŽœ’—ȱ˜ȱ
ȱ˜ȱŠ••ȱ ˜–Ž—ȱ ‘˜ȱœŒ›ŽŽ—ȱ™˜œ’’ŸŽȱ˜›ȱœ¢™‘’•’œǯ
Make plans for treating the baby at birth.
Record testing results and treatment in the facility’s logbook and in the woman’s card.

Audit
Input indicators
A national policy and locally adapted guidelines on syphilis prevention, management and care
in pregnant women are available and are correctly implemented.
The proportion of health facilities providing ANC that have a screening test for syphilis
available.
The availability of a screening test for syphilis in primary level health facilities.
The availability of penicillin at the primary care level (including ANC and childbirth care).
Health providers know when and how to perform the RPR test or VDRL (Venereal Disease
Research Laboratory) test or the test which is available in the facility.
Health providers know when and how to treat or refer women and their infants with syphilis.

Process and output indicators

Coverage of RPR testing (or other used test) in pregnant women in ANC.
Coverage of correct treatment in the ANC clinic.
Coverage of partners tested and treated accordingly.
Coverage of asymptomatic babies born to a positive mother who received prophylactic
treatment.
Outcome indicators
Incidence of congenital syphilis.
Perinatal and neonatal mortality and morbidity due to congenital syphilis.
Stillbirth rate.
Standards 1.3 Prevention of mother-to-child transmission of syphilis
Rationale
ž›Ž—ȱ˜ȱœžěŽ›’—
¢™‘’•’œȱ’œȱŠȱŒ‘›˜—’Œǰȱ˜ĞŽ—ȱ•ŠŽ—ȱ’—ŽŒ’˜—ȱ
with some clinically recognizable stages.
Where the disease is prevalent most cases may
be asymptomatic. Although estimates vary,
at least 50% of women with acute syphilis
œžěŽ›ȱŠŸŽ›œŽȱ™›Ž—Š—Œ¢ȱ˜žŒ˜–Žœǯȱ‘Žȱ
adverse pregnancy outcomes are estimated
˜ȱ‹Žȱ’œ›’‹žŽȱŠœȱ˜••˜ DZȱśŖƖȱŠ›Žȱœ’••‹’›‘œȱ
or spontaneous abortion, and 50% perinatal
death, serious neonatal infection or low birth
weight. Mortality in infected infants can be
higher than 10% (1).
The more recent the maternal infection, the
–˜›Žȱ•’”Ž•¢ȱ‘Žȱ’—Š—ȱ ’••ȱ‹ŽȱŠěŽŒŽȱ(2).
Transmission occurs more commonly in the
last two trimesters, but the spirochete can cross
the placenta at any time during pregnancy
(2). Clinical similarity with other congenital
diseases and the limitations of diagnostic tests
–Š”Žȱ’ȱ’ĜŒž•ȱ˜ȱŠ››’ŸŽȱŠȱŠ—ȱŽŠ›•¢ȱ’Š—˜œ’œȱ
in the newborn (1).
ĜŒŠŒ¢ȱŠ—ȱŽěŽŒ’ŸŽ—Žœœ
Syphilis control in pregnant women through
universal antenatal screening and treatment
of positive cases has been established as a
ŽŠœ’‹•ŽȱŠ—ȱŒ˜œȬŽěŽŒ’ŸŽȱ’—Ž›ŸŽ—’˜—ȱ(3,4),
especially owing to the high direct and indirect
cost of complications of syphilis in pregnancy
(5)ȱŠ—ȱ‘ŽȱŠŸŠ’•Š‹’•’¢ȱ˜ȱŒ‘ŽŠ™ȱŠ—ȱŽěŽŒ’ŸŽȱ
therapy (6–8). Nevertheless, in low-income
countries a number of technical, logistical and
structural constraints make case detection and
›ŽŠ–Ž—ȱ‘›˜ž‘ȱŠ—Ž—ŠŠ•ȱœŒ›ŽŽ—’—ȱ’ĜŒž•ȱ
(4,9), resulting in avoidable perinatal mortality
(10,11).
Non-treponemal tests such as RPR and VDRL
are helpful indicators of infection and are
cheaper and easier to perform than treponemal
tests. Their sensitivity increases from primary
˜ȱœŽŒ˜—Š›¢ȱœ¢™‘’•’œǰȱ ‘’•Žȱ‘Ž’›ȱœ™ŽŒ’ęŒ’¢ȱ’œȱ
generally high in the absence of an underlying
chronic condition (7); they are therefore useful
˜›ȱ˜••˜ Ȭž™ȱŠĞŽ›ȱ›ŽŠ–Ž—ȱ(6–8,12). Titres
’—ȱŠěŽŒŽȱ™Ž›œ˜—œȱžœžŠ••¢ȱ›’œŽȱ ’‘ȱ’—ŽŒ’˜—ȱ
Š—ȱŽŒ›ŽŠœŽȱŠĞŽ›ȱ›ŽŠ–Ž—ȱǻŝǼǯȱ‘Žȱ˜—Ȭœ’Žȱ
RPR test is quick and simple to use, and allows
treatment to be given immediately if indicated;
‘’œȱȃŠœȱ™›˜˜Œ˜•Ȅȱ‘Šœȱ™›˜ŸŽ—ȱŒ˜œȬŽěŽŒ’ŸŽȱ
’—ȱœŽĴ’—œȱ ‘Ž›Žȱœ¢™‘’•’œȱ™›ŽŸŠ•Ž—ŒŽȱ’œȱ‘’‘Ž›ȱ
than 0.15% (13). Nevertheless, these tests
–Š¢ȱ’ŸŽȱŠ•œŽȬ—ŽŠ’ŸŽȱ›Žœž•œȱ’—ȱ‘ŽȱŠěŽŒŽȱ
mother or her baby (7,14). RPR and VDRL
can also give false-positive results owing to
3
tissue damage from other causes, such as
viral infections, vaccinations, intravenal drug
abuse and chronic disease (7). Ideally, non-
›Ž™˜—Ž–Š•ȱŽœœȱœ‘˜ž•ȱ‹ŽȱŒ˜—ę›–Žȱ‹¢ȱŠȱ
treponemal test. Treponemal tests such as
the Treponema pallidum haemagglutination
assay (TPHA) have higher sensitivity and
œ™ŽŒ’ęŒ’¢ȱ‹žȱ˜ȱ—˜ȱŒ˜››Ž•ŠŽȱ ’‘ȱ’œŽŠœŽȱ
ŠŒ’Ÿ’¢ǰȱŠ›Žȱ’ĜŒž•ȱŠ—ȱŒ˜œ•¢ȱ˜ȱŒ˜—žŒǰȱ
and are thus not recommended for primary
health care facilities (7,15,16). Therefore, the
lack of resources and higher prevalence of
syphilis in less developed countries justify the
treatment of all people testing seropositive
with RPR (12).
New treponemal-based tests for syphilis make
˜—Ȭœ’ŽȱŽœ’—ȱŽŠœ’‹•Žǯȱ’–™•ŽȱŠ—ȱŽěŽŒ’ŸŽȱ
screening tests for syphilis are now available,
which can even be used at the lowest levels
of health service delivery. A simple strip of
paper, impregnated with treponemal antigen,
’œȱžœŽȱ˜ȱŽœȱ‹•˜˜ȱ˜‹Š’—Žȱ‹¢ȱꗐŽ›ȱ™›’Œ”ǯȱ
Results are available in just a few minutes.
These point-of-care diagnostic tests are
ŠŒŒž›ŠŽǰȱŠě˜›Š‹•ŽȱŠ—ȱœ’–™•Žȱ˜ȱ™Ž›˜›–ǯȱ
Unlike earlier diagnostic tests, they do not
require access to a laboratory or a refrigerator.
—ȱœ‘˜›ǰȱ‘Žȱ—Ž ȱŽœœȱ˜ěŽ›ȱŠȱ™›ŠŒ’ŒŠ•ȱ
alternative to older techniques. These tests
have the potential to change the whole
approach to syphilis testing even in isolated
clinics. Because the results can be available
immediately, women can be tested and receive
treatment at the same visit. The new tests cost
a mere US$ 0.93-1.44 per woman screened
(16). Although this is more costly than the
previous standard tests, the new tests are in
ŠŒȱ–˜›ŽȱŒ˜œȬŽěŽŒ’ŸŽǰȱœ’—ŒŽȱ–˜›Žȱ ˜–Ž—ȱ
can be tested and treated in a timely manner
and hence more cases of congenital syphilis
prevented. It is estimated that the new rapid
›Ž™˜—Ž–Š•ȱ‹ŠœŽȱŽœœȱŒ˜œȱ˜—•¢ȱǞȱŝȱ˜›ȱ
each case of congenital syphilis averted (17).
Adequate penicillin treatment usually ends
infectivity within 24–48 hours. A Cochrane
review (18) indicates that, while there is no
˜ž‹ȱ‘Šȱ™Ž—’Œ’••’—ȱ’œȱŽěŽŒ’ŸŽȱ’—ȱ›ŽŠ’—ȱ
syphilis in pregnancy and in preventing
congenital syphilis, uncertainty remains about
the optimal treatment regimen (dose, duration
and preparation) (18). Benzylpenicillin,
administered parenterally in a single dose,
is the preferred drug for treating pregnant
women and prevent mother-to-child
transmission of syphilis (6–8,18).
Standards 1.3 Prevention of mother-to-child transmission of syphilis 4

Single dose, however, won’t treat latent
syphilis in pregnant women. Based on
the available evidence, pregnant women
with a history of penicillin allergy should
be desensitized before treatment with
benzylpenicillin (8).
International guidelines recommend that
every woman who tests seropositive for
syphilis be also tested for HIV infection (8).
Although there is no conclusive evidence,
it is possible that HIV coinfection alters the
predictive value of diagnostic tests (7,8,15).
HIV coinfection could increase the possibility
of early development of neurosyphilis and
could increase the possibility of treatment
failure; some guidelines therefore suggest
modifying currently recommended dose
regimens in the case of HIV coinfection
(6–8) (see also standard 1.2 “Prevention and
–Š—ŠŽ–Ž—ȱ˜ȱœŽ¡žŠ••¢ȱ›Š—œ–’ĴŽȱŠ—ȱ
reproductive tract infections”).

The table below summarizes the evidence from the most relevant studies. The level of evidence is
presented using the NICE methodology which applies a coding from 1 (high level) to 4 (low level).
For details, see also the —›˜žŒ’˜—ȱ˜ȱ‘ŽȱŠ—Š›œȱ˜›ȱŠŽ›—Š•ȱŠ—ȱŽ˜—ŠŠ•ȱŠ›Žȱand theȱ›˜ŒŽœœȱ
˜ȱŽŸŽ•˜™ȱ‘ŽȱŠ—Š›œȱ˜›ȱŠŽ›—Š•ȱŠ—ȱŽ˜—ŠŠ•ȱŠ›Žȱ˜—ȱ‘Ĵ™DZȦȦ   ǯ ‘˜ǯ’—Ȧ–Š”’—ȏ™›Ž—Š—Œ¢ȏ
safer/publications/en. For an overview of a comprehensive list of evidence, please refer to the
reference section of the standard.

Study
Population & Outcomes linked
ǻ¢™ŽȱǭȱŽŸŽ•ȱ ‹“ŽŒ’ŸŽȱǭȱ—Ž›ŸŽ—’˜— Results Comments
ŽĴ’— to the Standard
˜ȱŽŸ’Ž—ŒŽǼ
10. Rotchford 158 pregnant To study the impact on Inadequate syphilis 30% Žœ™’ŽȱŽěŽŒ’ŸŽȱ
et al. 2000 women with perinatal mortality of treatment screening,
syphilis inadequate treatment for Š›—Ž›ȱ—˜’ęŒŠ’˜— ŝŝƖ many pregnant
‹œŽ›ŸŠ’˜—Š•ȱ maternal syphilis Partner treatment 26% women with
study ANC clinical despite adequate screening syphilis remain
2+ œŽĴ’—Dzȱ˜ž‘ȱ inadequately
Africa treated,
Žę—’’˜— Perinatal death Adequate vs resulting in
Baseline risk – Complete syphilis inadequate avoidable
– Syphilis ›ŽŠ–Ž—DZȱ‘›ŽŽȱ˜œŽœȱ treatment perinatal
prevalence of penicillin at weekly a
mortality
among pregnant intervals (2.4 mega-units of NNT 5 (3–13)
women 9% benzathine benzylpenicillin
(8–10%) intramuscularly)
– Perinatal death – Adequate syphilis
’—ȱ˜ěœ™›’—ȱ˜ȱ ›ŽŠ–Ž—DZȱ ˜ȱ˜›ȱ–˜›Žȱ
inadequately doses of penicillin
treated pregnant – Inadequate syphilis
women with ›ŽŠ–Ž—DZȱ˜—Žȱ˜›ȱ—˜ȱ˜œŽœȱ
syphilis 20% of penicillin
18. Walker 2004 26 studies met To identify the most While there
the criteria for ŽěŽŒ’ŸŽȱŠ—’‹’˜’Œȱ›Ž’–Ž—ȱ is no doubt
Most recent detailed scrutiny; for syphilis in pregnant that penicillin
substantive none of the studies women, with and without ’œȱŽěŽŒ’ŸŽȱ’—ȱ
amendment included in the concomitant HIV infection the treatment
March 2001 review of syphilis in
pregnancy and
Systematic in the prevention
›ŽŸ’Ž ȱ of congenital
1++ syphilis,
uncertainty
remains about
optimum
treatment
regimens
a
Number needed to treat
Standards 1.3 Prevention of mother-to-child transmission of syphilis 5

Study
Title & author/
ǻ¢™ŽȱǭȱŽŸŽ•ȱ Contents of the recommendations Comments
organization
˜ȱŽŸ’Ž—ŒŽǼ
8. CDC 2002 Ž¡žŠ••¢ȱ›Š—œ–’ĴŽȱ All patient who have syphilis should be tested for HIV Parenteral
diseases treatment infection. benzylpenicillin has
Guideline guidelines ‹ŽŽ—ȱžœŽȱŽěŽŒ’ŸŽ•¢ȱ
4 Coinfection with HIV can increase the risk of neurologic for syphilis treatment
Centres for Disease complication and the risk of treatment failure with currently and prevention for
Control and recommended regimens. more than 50 years;
Prevention nevertheless, no
All women should be screened serologically for syphilis at comparative trials
United States ‘Žȱꛜȱ™›Ž—ŠŠ•ȱŸ’œ’ǯȱ—ȱœŽĴ’—ȱ˜ȱ‘’‘ȱœ¢™‘’•’œȱ™›ŽŸŠ•Ž—ŒŽǰȱ have been adequately
serologic testing should be performed twice during the third conducted to guide
trimester. the selection of an
optimal regimen
Š›Ž—Ž›Š•ȱŽ—’Œ’••’—ȱ ȱ’œȱ‘Žȱ˜—•¢ȱ‘Ž›Š™¢ȱ ’‘ȱ˜Œž–Ž—Žȱ (dose, duration and
ŽĜŒŠŒ¢ȱ˜›ȱœ¢™‘’•’œȱž›’—ȱ™›Ž—Š—Œ¢ǯ preparation)

Based on available evidence, pregnant women who have a

history of penicillin allergy should be desensitized and treated
with penicillin

References
ŗǯȱ Š•˜˜“ŽŽȱ
ȱŽȱŠ•ǯȱ‘Žȱ™›ŽŸŽ—’˜—ȱŠ—ȱ–Š—ŠŽ–Ž—ȱ˜ȱŒ˜—Ž—’Š•ȱœ¢™‘’•’œDZȱŠ—ȱ˜ŸŽ›Ÿ’Ž ȱŠ—ȱ
recommendations. ž••Ž’—ȱ˜ȱ‘Žȱ˜›•ȱ
ŽŠ•‘ȱ›Š—’£Š’˜—ǰȱŘŖŖŚǰȱŞŘDZŚŘŚȮŚřŖǯ
Řǯȱ Ž›–Š—ȱǯȱŠŽ›—Š•ȱœ¢™‘’•’œDZȱ™Š‘˜™‘¢œ’˜•˜¢ȱŠ—ȱ›ŽŠ–Ž—ǯȱž••Ž’—ȱ˜ȱ‘Žȱ˜›•ȱ
ŽŠ•‘ȱ
›Š—’£Š’˜—ǰȱŘŖŖŚǰȱŞŘDZŚřřȮŚřŞǯȱ
3. Connor N, Roberts J, Nicoll A. Strategic options for antenatal screening for syphilis in the
—’Žȱ ’—˜–DZȱŠȱŒ˜œȱŽěŽŒ’ŸŽ—ŽœœȱŠ—Š•¢œ’œǯȱ˜ž›—Š•ȱ˜ȱŽ’ŒŠ•ȱŒ›ŽŽ—’—ǰȱŘŖŖŖǰȱŝDZŝȮŗřǯ
4. Schmid G. Economic and programmatic aspect of congenital syphilis prevention. ž••Ž’—ȱ˜ȱ
‘Žȱ˜›•ȱ
ŽŠ•‘ȱ›Š—’£Š’˜—ǰȱŘŖŖŚǰȱŞŘDZŚŖŘȮŚŖşǯ
5. Bateman DA et al. The hospital cost of congenital syphilis. ˜ž›—Š•ȱ˜ȱŽ’Š›’ŒœǰȱŗşşŝǰȱŗřŖDZŝśŘȮ
ŝśŞǯ
Ŝǯȱ žœ‘Ž›ȱǰȱ
Š–’••ȱǰȱŠž‘—ȱǯȱ쎌ȱ˜ȱ‘ž–Š—ȱ’––ž—˜ŽęŒ’Ž—Œ¢ȱŸ’›žœȱǻ
Ǽȱ’—ŽŒ’˜—ȱ
on the course of syphilis and on the response to treatment. ——Š•œȱ˜ȱ—Ž›—Š•ȱŽ’Œ’—Ž, 1990,
ŗŗřDZŞŝŘȮŞŞŗǯ
ŝǯȱ ȱ›ŽŸŽ—’ŸŽȱŽ›Ÿ’ŒŽœȱŠœ”ȱ˜›ŒŽǯȱ˜ž—œŽ•’—ȱ˜ȱ™›ŽŸŽ—ȱ
ȱ’—ŽŒ’˜—ȱŠ—ȱ˜‘Ž›ȱœŽ¡žŠ••¢ȱ
›Š—œ–’ĴŽȱ’œŽŠœŽœǯȱ—DZȱ ž’Žȱ˜ȱŒ•’—’ŒŠ•ȱ™›ŽŸŽ—’ŸŽȱœŽ›Ÿ’ŒŽœ, 2nd ed. Rockville, MD, Agency for

ŽŠ•‘ŒŠ›ŽȱŽœŽŠ›Œ‘ȱŠ—ȱžŠ•’¢ǰȱŗşşŜǰȱŝŘřȮŝřŝǯ
Şǯȱ Ž—Ž›œȱ˜›ȱ’œŽŠœŽȱ˜—›˜•ȱŠ—ȱ›ŽŸŽ—’˜—ǯȱŽ¡žŠ••¢ȱ›Š—œ–’ĴŽȱ’œŽŠœŽœȱ›ŽŠ–Ž—ȱž’Ž-
lines – 2002. ˜›‹’’¢ȱŠ—ȱ˜›Š•’¢ȱŽŽ”•¢ȱŽ™˜›ǰȱŘŖŖŘǰȱśŗDZŗȮŞŖǯ
şǯȱ Ž™Ž›‘ŽœȱȱŽȱŠ•ǯȱŠŽ›—Š•ȱŠ—ȱŒ˜—Ž—’Š•ȱœ¢™‘’•’œȱ™›˜›Š––ŽœDZȱŒŠœŽȱœž’Žœȱ’—ȱ˜•’Ÿ’Šǰȱ
Kenya and South Africa. ž••Ž’—ȱ˜ȱ‘Žȱ˜›•ȱ
ŽŠ•‘ȱ›Š—’£Š’˜—ǰȱŘŖŖŚǰȱŞŘDZŚŗŖȮŚŗŜǯ
10. Rotchford K et al. Impact on perinatal mortality of missed opportunities to treat maternal
œ¢™‘’•’œȱ’—ȱ›ž›Š•ȱ˜ž‘ȱ›’ŒŠDZȱ‹ŠœŽ•’—Žȱ›Žœž•œȱ›˜–ȱŠȱŒ•’—’Œȱ›Š—˜–’£ŽȱŒ˜—›˜••Žȱ›’Š•ǯȱ
›˜™’ŒŠ•ȱŽ’Œ’—Žȱǭȱ—Ž›—Š’˜—Š•ȱ
ŽŠ•‘ǰȱŘŖŖŖǰȱśDZŞŖŖȮŞŖŚǯ
11. Goldenberg RL, Thompson C. The infectious origins of stillbirth. –Ž›’ŒŠ—ȱ˜ž›—Š•ȱ˜ȱ‹œŽ›’Œœȱ
Š—ȱ ¢—ŽŒ˜•˜¢ǰȱŘŖŖřǰȱŗŞşDZŞŜŗȮŞŝřǯ
ŗŘǯȱ ŽŽ•’—ȱǯȱ’Š—˜œ’Œȱ˜˜•œȱ˜›ȱ™›ŽŸŽ—’—ȱŠ—ȱ–Š—Š’—ȱ–ŠŽ›—Š•ȱŠ—ȱŒ˜—Ž—’Š•ȱœ¢™‘’•’œDZȱ
an overview. ž••Ž’—ȱ˜ȱ‘Žȱ˜›•ȱ
ŽŠ•‘ȱ›Š—’£Š’˜—ǰȱŘŖŖŚǰȱŞŘDZŚřşȮŚŚŜǯ
ŗřǯȱ ’•‹Ž›œŽ’—ȱ ȱŽȱŠ•ǯȱ쎌’ŸŽ—ŽœœȱŠ—ȱŒ˜œȮ‹Ž—Žęȱ˜ȱŽ—‘Š—ŒŽ–Ž—œȱ˜ȱŠȱœ¢™‘’•’œȱœŒ›ŽŽ—’—ȱ
and treatment program at a county jail. Ž¡žŠ••¢ȱ›Š—œ–’ĴŽȱ’œŽŠœŽœǰȱŘŖŖŖǰȱŘŝDZśŖŞȮśŗŝǯ
ŗŚǯȱ ŠŸŠ—£˜ȱȱŽȱŠ•ǯȱŽ˜—ŠŠ•ȱŠ—ȱ™˜œȬ—Ž˜—ŠŠ•ȱ˜—œŽȱ˜ȱŽŠ›•¢ȱŒ˜—Ž—’Š•ȱœ¢™‘’•’œDZȱŠȱ›Ž™˜›ȱ›˜–ȱ
Mozambique. ——Š•œȱ˜ȱ›˜™’ŒŠ•ȱŠŽ’Š›’ŒœǰȱŗşşŘǰȱŗŘDZŚŚśȮŚśŖǯ
ŗśǯȱ žŽ—‹›Šž—ȱȱŽȱŠ•ǯȱ›Ž™˜—Ž–Š•ȱœ™ŽŒ’ęŒȱŽœœȱ˜›ȱ‘ŽȱœŽ›˜’Š—˜œ’œȱ˜ȱœ¢™‘’•’œǯȱ¢™‘’•’œȱŠ—ȱ
HIV Study Group. Ž¡žŠ••¢ȱ›Š—œ–’ĴŽȱ’œŽŠœŽœǰȱŗşşŞǰȱŘśDZśŚşȮśśŘǯ
 Standards 1.3 Prevention of mother-to-child transmission of syphilis 6

ŗŜǯȱ Ž››’œȬ›Žœ‘˜•ȱȱŽȱŠ•ǯȱœȱŠ—Ž—ŠŠ•ȱœ¢™‘’•’œȱœŒ›ŽŽ—’—ȱœ’••ȱŒ˜œȬŽěŽŒ’ŸŽȱ’—ȱœž‹ȬŠ‘Š›Š—ȱ

Africa? Ž¡žŠ••¢ȱ›Š—œ–’ĴŽȱ—ŽŒ’˜—œǰȱŘŖŖřǰȱŝşDZřŝśȬřŞŗǯ
ŗŝǯȱ ›˜—£Š—ȱȱŽȱŠ•ǯȱȱ—Ȭ’Žȱ›Š™’ȱŠ—Ž—ŠŠ•ȱœ¢™‘’•’œȱœŒ›ŽŽ—’—ȱ ’‘ȱŠ—ȱ’––ž—˜Œ‘›˜–Š˜›Š™‘’Œȱ
strip improves case detection and treatment in rural South African clinics, ž••Ž’—ȱ˜ȱ‘Žȱ
˜›•ȱ
ŽŠ•‘ȱ›Š—’£Š’˜—ȱǻœž‹–’ĴŽǰȱŘŖŖśǼǯȱȱ
ŗŞǯȱ Š•”Ž›ȱ ǯȱ—’‹’˜’Œœȱ˜›ȱœ¢™‘’•’œȱ’Š—˜œŽȱž›’—ȱ™›Ž—Š—Œ¢ȱǻ˜Œ‘›Š—ŽȱŽŸ’Ž Ǽǯȱ—DZȱ‘Žȱ
˜Œ‘›Š—Žȱ’‹›Š›¢ǰȱœœžŽȱŚǰȱŘŖŖŚǯȱ‘’Œ‘ŽœŽ›ǰȱ˜‘—ȱ’•Ž¢ȱǭȱ˜—œǰȱŘŖŖŚǯ

Links and additional sources

I. Ž¡žŠ••¢ȱ›Š—œ–’ĴŽȱŠ—ȱ˜‘Ž›ȱ›Ž™›˜žŒ’ŸŽȱ›ŠŒȱ’—ŽŒ’˜—œǯȱȱž’Žȱ˜ȱŽœœŽ—’Š•ȱ™›ŠŒ’ŒŽ.
Ž—ŽŸŠǰȱ˜›•ȱ
ŽŠ•‘ȱ›Š—’£Š’˜—ǰȱŘŖŖśȱǻ‘Ĵ™DZȦȦ   ǯ ‘˜ǯ’—Ȧ›Ž™›˜žŒ’ŸŽȬ‘ŽŠ•‘Ȧ
™ž‹•’ŒŠ’˜—œȦ›’œȏŽ™Ȧ’—Ž¡ǯ‘–ǰȱŠŒŒŽœœŽȱŘȱŽ‹›žŠ›¢ȱŘŖŖŜǼǯ
II. ——žŠ•ȱŽŒ‘—’ŒŠ•ȱ›Ž™˜›ȱŘŖŖŘǯȱŽŒ’˜—ȱřǯȱ˜—›˜••’—ȱœŽ¡žŠ••¢ȱ›Š—œ–’ĴŽȱŠ—ȱ›Ž™›˜žŒ’ŸŽȱ›ŠŒȱ
’—ŽŒ’˜—œǯȱ Ž—ŽŸŠǰȱ˜›•ȱ
ŽŠ•‘ȱ›Š—’£Š’˜—ǰȱŘŖŖŘȱǻ‘Ĵ™DZȦȦ   ǯ ‘˜ǯ’—Ȧ›Ž™›˜žŒ’ŸŽȬ
‘ŽŠ•‘Ȧ™ž‹•’ŒŠ’˜—œȦŠ——žŠ•ȏŽŒ‘—’ŒŠ•ȏ›Ž™˜›œȦŘŖŖŘȦ’—Ž¡ǯ‘–•ǰȱŠŒŒŽœœŽȱŞȱŠ›Œ‘ǰȱŘŖŖŜǼǯ
III. ˜‘Ž›Ȯ‹Š‹¢ȱ™ŠŒ”ŠŽDZȱ’–™•Ž–Ž—’—ȱœŠŽȱ–˜‘Ž›‘˜˜ȱ’—ȱŒ˜ž—›’Žœ. Geneva, World Health
›Š—’£Š’˜—ǰȱŗşşŜȱǻ˜Œž–Ž—ȱ
Ȧ
ȦȦȱşŚǯŗŗǼȱǻ‘Ĵ™DZȦȦ   ǯ ‘˜ǯ’—Ȧ
›Ž™›˜žŒ’ŸŽȬ‘ŽŠ•‘Ȧ™ž‹•’ŒŠ’˜—œȦȏşŚȏŗŗȦȏşŚȏŗŗȏŠ‹•Žȏ˜ȏŒ˜—Ž—œǯŽ—ǯ‘–•ǰȱ
accessed 13 December 2004).
IV. Š›Žȱ˜ȱ–˜‘Ž›ȱŠ—ȱ‹Š‹¢ȱŠȱ‘Žȱ‘ŽŠ•‘ȱŒŽ—›ŽDZȱŠȱ™›ŠŒ’ŒŠ•ȱž’Ž. Geneva, World Health
›Š—’£Š’˜—ǰȱŗşşŝȱǻ˜Œž–Ž—ȱ
Ȧ
ȦȦşŚǯŘǼȱǻ‘Ĵ™DZȦȦ   ǯ ‘˜ǯ’—Ȧ
›Ž™›˜žŒ’ŸŽȬ‘ŽŠ•‘Ȧ™ž‹•’ŒŠ’˜—œȦ–œ–ȏşŚȏŘȦ–œ–ȏşŚȏŘȏŗǯ‘–•ǰȱŠŒŒŽœœŽȱŗřȱŽŒŽ–‹Ž›ȱ
2004).
V. Cloherty JP, Stark A, Eichenwald E. Š—žŠ•ȱ˜ȱ—Ž˜—ŠŠ•ȱŒŠ›Žǯȱ’™™’—Œ˜Ĵȱ’••’Š–œȱǭȱ
Wilkins, 1998.
VI. ›Ž—Š—Œ¢ǰȱŒ‘’•‹’›‘ǰȱ™˜œ™Š›ž–ȱŠ—ȱ—Ž ‹˜›—ȱŒŠ›ŽDZȱŠȱž’Žȱ˜›ȱŽœœŽ—’Š•ȱ™›ŠŒ’ŒŽ. Geneva,
˜›•ȱ
ŽŠ•‘ȱ›Š—’£Š’˜—ǰȱŘŖŖřȱǻ‘Ĵ™DZȦȦ ‘š•’‹˜Œǯ ‘˜ǯ’—Ȧ™ž‹•’ŒŠ’˜—œȦŘŖŖřȦ
şŘŚŗśşŖŞŚǯ™ǰȱŠŒŒŽœœŽȱŝȱŽŒŽ–‹Ž›ȱŘŖŖŚǼǯ

Š—Š›œȱ˜›ȱŠŽ›—Š•ȱŠ—ȱŽ˜—ŠŠ•ȱŠ›ŽȱŽŽ›’—ȱ˜––’ĴŽŽȱȱ
‘Š’›DZȱŠž•ȱŠ—ȱ˜˜”ǰȱ’›ŽŒ˜›ǰȱŽ™Š›–Ž—ȱ˜ȱŽ™›˜žŒ’ŸŽȱ
ŽŠ•‘ȱŠ—ȱŽœŽŠ›Œ‘Dzȱȱȱȱȱȱȱȱȱȱȱȱ
This document This document is part of the ›—Ž••Šȱ’—ŒŽĴ˜ǰȱ
Ž•Šȱ˜œŠǰȱŽ••Šȱ‘Ž››ŠĴǰȱ——’Žȱ˜›Ž•Šǰȱ’Šȱ Š‹›ŠȱŠ—ȱžŒȱŽȱŽ›—’œȱ
is not a formal Standards for Maternal and Neonatal (Department of Making Pregnancy Safer).
publication of Š›ŽȱŽŸŽ•˜™Žȱ‹¢ȱ‘ŽȱŽ™Š›–Ž—ȱ
of Making Pregnancy Safer, Œ”—˜ •Ž–Ž—œȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ
the World Health
‘’œȱœŠ—Š›ȱ ŠœȱŽŸŽ•˜™Žȱ‹¢ȱ›—Ž••Šȱ’—ŒŽĴ˜ȱ ’‘ȱŸŠ•žŠ‹•Žȱ’—™žœȱ›˜–ȱ–Ž–‹Ž›œȱ˜ȱ‘Žȱ
Organization ˜›•ȱ
ŽŠ•‘ȱ›Š—’£Š’˜—ǯȱȱ
Š‹˜ŸŽȱŽŽ›’—ȱ˜––’ĴŽŽȱŠ—ȱ
ȱŽ’˜—Š•ȱĜŒŽœȱŠ—ȱ›ŽŸ’Ž ŽȱŠȱŠȱŽŒ‘—’ŒŠ•ȱ˜—œž•Š’˜—ȱ
(WHO), and ’—ȱ Ž—ŽŸŠǰȱŗŚȬŗŜȱŒ˜‹Ž›ȱŘŖŖŘǯȱŽ–‹Ž›œȱ˜ȱ‘ŽȱŽ—Ž›ȱ˜›ȱŽŸŠ•žŠ’˜—ȱ˜ȱŽěŽŒ’ŸŽ—Žœœȱ˜ȱ‘ŽŠ•‘ȱ
all rights are For further information please ŒŠ›ŽȬŽȱǻ’–˜—Šȱ’ȱŠ›’˜ǰȱ’Ĵ˜›’˜ȱŠœŽŸ’ǰȱ ’Š—›Š—Œ˜ȱ ˜›’ǰȱŠ—’Ž•Šȱ™ŽĴ˜•’ǰȱŠ—Žȱ
reserved by the contactDZ Baronciani and Nicola Magrini) developed the table of evidence and provided additional
Organization. Department of Making Pregnancy ’—œ’‘ž•ȱ›ŽŸ’Ž ȱ˜ȱ‘ŽȱŽŸ’Ž—ŒŽȱœŽŒ’˜—ǯȱŽȱ‘Š—”ȱŠ‘Š•’Žȱ›˜žŽȱŠ—ȱŠĴ‘Ž œȱŠĴ‘Š’ȱ˜›ȱ
The document Safer (MPS) ‘Ž•™ž•ȱŒ˜––Ž—œȱ˜—ȱ‘ŽȱœŽŸŽ›Š•ȱ›ŠĞœǰȱ›Š—”ȱŽŒ”œ˜—ȱ˜›ȱ‘ŽȱŽ’’—ȱŠ—ȱž”Žȱ ¢Š–Ž›Š‘ȱ˜›ȱ
may, however, be World Health Organization (WHO) the layout.
freely reviewed, 20 Avenue Appia
abstracted, WHO acknowledges the generous contribution of over 80 individuals and organizations in the
ŗŘŗŗȱ Ž—ŽŸŠȱŘŝ
reproduced and ꎕȱ˜ȱ–ŠŽ›—Š•ȱŠ—ȱ—Ž˜—ŠŠ•ȱ‘ŽŠ•‘ȱ ‘˜ȱ˜˜”ȱ’–Žȱ˜ȱ›ŽŸ’Ž ȱ‘’œȱ˜Œž–Ž—ȱŠȱ’쎛Ž—ȱœŠŽœȱ
Switzerland
translated, in part of its development.
or in whole, but Ž•DZȱƸŚŗȱŘŘȱŝşŗȱřřŝŗ
Š¡DZȱƸŚŗȱŘŘȱŝşŗȱśŞśř The funding towards the preparation and production of this document provided by the
not for sale nor for
–Š’•DZȱ’—˜ȓ ‘˜ǯ’— Governments of Australia, Italy and USA is gratefully acknowledged. In addition, WHO’s
use in conjunction
Ž‹ȱœ’ŽDZȱ   ǯ ‘˜ǯ’—Ȧ–Š”’—ȏ Making Pregnancy Safer Department is grateful to the Governments of Denmark, Ireland,
with commercial Netherlands, Norway, Sweden, and the United Kingdom, and to the World Bank, UNICEF
purposes. ™›Ž—Š—Œ¢ȏœŠŽ›Ȧ™ž‹•’ŒŠ’˜—œȦŽ—Ȧ
Š—ȱȱ˜›ȱž—œ™ŽŒ’ꮍȱ™›˜›Š––Žȱœž™™˜›ǯȱ