In response to sustained increases in CS cases, in April 2022, MCDPH launched the Think Syphilis campaign to increase provider knowledge through educational outreach and distribution of promotional materials to more than 600 obstetrician-gynecologist (Ob/Gyn) providers, pediatricians, midwives, infectious disease providers, clinical staff in emergency room departments, and public and private clinics around Maricopa County. Educational packet materials included a maternal syphilis screening checklist, a neonate evaluation and treatment flowchart for CS, a Maricopa CS statistics flyer, an updated 2022 Maricopa County Public Health Order for prenatal syphilis screening, Think Syphilis promotional stickers, and MCDPH STI Clinic business cards.

MCDPH staff developed a provider survey (Supplemental File 1) and performed two pilot evaluations with MCDPH STI clinic medical providers, comprised of nurse practitioners and nurses (n = 5), followed by the MCDPH STI communicable disease investigators (CDIs) (n = 13). Pilot feedback on the survey content was integrated before launch. Between November 2022 and May 2023, MCDPH conducted medical provider and facility-based surveys to characterize prenatal screening and treatment services for maternal syphilis. Questions comprised three major themes: syphilis screening practices, BPG treatment practices and barriers, and Think Syphilis materials acknowledgment. The survey included multi-select, multiple-choice, and free-text questions.

The survey and administration methods were reviewed within the protocols, Facility and Provider-Level Maternal Syphilis Screening and Treatment Practices in Maricopa County, Arizona, and given a non-research determination by the Arizona Department of Health Services (ADHS) Human Subjects Review Board (HSRB #22-0001).

To ensure comprehensive representation of prenatal and obstetrical care services available to pregnant women in Maricopa County, a list of medical providers delivering infants in Maricopa County in 2021 was obtained from the ADHS Office of Infectious Disease Services and Vital Statistics to identify providers accounting for the top 70% of deliveries. This list was then used to survey providers and identify associated providers and facilities. Survey responses were accepted from these providers or their clinic staff members including obstetricians, nurses, or clinical administrative staff members with direct knowledge of facility-level syphilis screening and treatment practices.

Surveys were administered using multiple modalities including paper surveys delivered in-person or by mail, as well as surveys conducted via telephone, fax, and email. Five project staff used a standard survey and script to minimize measurement error under consistent conditions for surveys conducted over the phone. A total of four contact attempts were performed by MCDPH staff to increase response rates. When a prenatal care provider was unavailable, the survey was completed by a clinic representative with direct knowledge of facility-based syphilis screening and treatment practices. In April 2023, 20 paper copies of the survey were distributed to delivering providers attending a local obstetrical society meeting. An additional 38 letters inclusive of a paper copy of the survey with return postage provided were sent by mail.

Qualtrics was used as the survey instrument and captured survey respondent data during phone-based interviews. When paper-based copies were utilized by either survey respondents or MCDPH STI Program staff, responses were hand-entered into Qualtrics. Participants who opted for survey completion by email were provided a user-specific survey link to complete the survey online. Those who declined to participate were offered Think Syphilis campaign materials.

Among the sample of delivering providers, one respondent per prenatal health facility was included for analysis, with priority given to responses from medical providers delivering prenatal care. In cases where multiple providers in the sample worked within the same facility, a single individual was selected to represent the facility. When more than one respondent was a medical provider delivering prenatal care directly within the same parent corporation, the earliest completed survey was used for analysis. Survey responses were applied to all delivering providers at the same facility, as well as to their respective satellite offices assuming consistent practices within a single corporation. Infant representation in the survey was calculated as the number of infants delivered by providers represented in the survey, collected from the ADHS vital registry list of live births, divided by the total number of deliveries in Maricopa County in 2021. Facility response rate was calculated by taking the amount of parent facilities surveyed by the total amount of parent facilities in our sample.

During analysis, respondents who did not respond to individual questions or who were not presented with a particular question due to conditional logic were excluded from denominator percentage calculations for those specific questions. To assess facility-level delivery of syphilis screening at each timepoint in compliance with county mandates, participant-reported estimates were collected on the proportion (%) of pregnant women receiving antenatal care at each facility who were screened for syphilis. For review of delivery-based hospital screening practices, we limited our sample subset to delivering physicians and allied health professionals (categorized as physician assistants, nurses, nurse practitioners, and nurse managers) who were likely to have direct knowledge of inpatient maternal syphilis screening practices at the time of delivery. Additionally, facilities were categorized into the following site types: Private Provider, Private Hospital, Federally Qualified Health Center (FQHC), Indian Health Service (IHS), and Public Hospital. Facility types were assigned and reviewed through use of internet search. Data were extracted from Qualtrics and analyzed using SAS Enterprise Guide (v8.3, Cary, North Carolina).

From November 2022 through May 2023, contact attempts were made to the 66 unique facilities or corporations employing the top 190 delivering providers accounting for 70% (37,745/50,245) of all reported live births in Maricopa County. Of the 66 facilities, 42 surveys were completed by a provider or eligible clinic staff member (one per facility) and included in our analysis for a facility-level response rate of 64%.

These 42 facilities represented 129 delivering providers and accounted for 72% (27,221/37,745) of all live births in the sample and 54% (27,221/50,245) of all reported live births in Maricopa County for 2021. Of our sample, the provider response rate is 67.9% (129/190). Consequently, 32% (61/190) of the providers in our sample were not surveyed due to non-response from their respective facilities. When including providers outside of the respondent sample working within the same corporation, the distinct healthcare facilities represented by the survey included 232 total delivering providers accounting for 33,916 deliveries in Maricopa County in 2021, approximately 68% of all live births that year (Figure 1).

Of the 60 responses received, 42 surveys from distinct healthcare facilities were included for analysis. Excluded surveys included 13 duplicate respondents by clinic site and 5 surveys that were incomplete for analysis.

The 42 included surveys represent 42 unique facilities which encompass 104 outpatient Ob/Gyn central and satellite clinics. Among surveys included for analysis, 40.5% (17/42) were completed directly by an obstetrician-gynecologist, 23.8% (10/42) by clinical nursing/allied health professionals, and 35.7% (15/42) by administrative and support staff knowledgeable of syphilis screening practices.

Facility types represented by survey respondents included, 85.7% (36/42) private clinics, 4.8% (2/42) private hospital organizations, 4.8% (2/42) FQHC, 2.4% (1/42) IHS, and 2.4% (1/42) as a public hospital. Among all 33,916 deliveries represented by this survey, private clinics accounted for 88%, FQHCs and private hospitals each accounted for 5%, and public hospitals and the IHS each represented 1%. Among respondents, 97.6% (40/41) indicated that their facility provided care to uninsured patients. Moreover, 42.1% (16/38) of respondents indicated that at least 60% of their pregnant patients are on Medicaid.

All 42 (100%) respondents reported testing for syphilis at least once during prenatal care. Moreover, 97.6% (41/42) respondents indicated their facility held an established syphilis screening policy for pregnant patients, and 95.2% (40/42) reported having an existing standing order for prenatal laboratory testing inclusive of syphilis. When assessing compliance with components of the Maricopa County Public Health Order, 78.6% (33/42) respondents reported testing pregnant patients for syphilis at the first prenatal visit. Similarly, 73.8% (31/42) respondents reported testing all pregnant patients during the third trimester.

Among responding survey participants, 74.1% (20/27) reported all pregnant patients are tested at delivery. When only including physicians or other delivering providers knowledgeable of hospital-based screening practices, 76.5% (13/17) reported syphilis screening at delivery. When assessing potential future prevention efforts, among respondents, 42.5% (17/40) facilities indicated interest in implementing rapid syphilis testing (fingerstick) at their facility for pregnant patients.

Regarding syphilis treatment practices and BPG availability, 16.6% (7/42) described prescribing BPG for patients to pick up at a pharmacy and return for an in-clinic injection. Only 11.9% (5/42) reported that their facilities stock BPG and staff treat on-site. Of these 5 facilities that stocked BPG, one was IHS, two were FQHCs, one was a public hospital, and one was a private clinic. Referral of patients to an external treatment site for BPG was reported by 71.4% (30/42) respondents. The MCDPH STI Clinic was the most reported treatment referral site by 91% (19/21) of respondents providing this information, with an additional 4.8% (1/21) indicating they both administer treatment on-site and refer to the MCDPH STI Clinic.

When respondents were presented a multi-select question assessing why patients were not treated for syphilis at their clinical facility, 63.6% (21/33) perceived syphilis as rare (implying very infrequent diagnoses), 18.2% (6/33) described issues with cost of treatment, 21.2% (7/33) issues with procurement of BPG, 12.1% (4/33) concerns for BPG expiration, 3.0% (1/33) reported they did not perform any injections directly in their clinic, 30.3% (10/33) listed other reasons, and 6.1% (2/33 ) indicated no barriers to report. Among the 10 respondents reporting other reasons, 20.0% (2/10) reported uncertainty as to why treatment was not directly provided at their facility. The remaining 80.0% (8/10) respondents described various factors, including BPG administration logistics, uncertainty regarding treatment guidelines, and preference for referral to the MCDPH STI Clinic to ensure appropriate treatment, follow-up, and management of sexual partners. There were 60.0% (24/40) who indicated interest in having an MCDPH mobile health unit team directly provide BPG treatment to facilities’ consenting syphilitic pregnant patients.

There were 22.0% (9/41) respondents that indicated they received Think Syphilis campaign provider education materials mailed by MCDPH; 34.2% (14/41) reported they were unaware if materials were received. Among the 9 respondents confirming receipt of Think Syphilis campaign materials, 77.8% (7/9) reported they shared the materials with their office staff, 55.6% (5/9) shared the materials with medical providers, 66.7% (6/9) posted the materials in their facility, 44.4% (4/9) reviewed their lab protocols, 33.3% (3/9 ) reviewed their standing orders, 44.4% (4/9) developed or changed lab protocols or standing orders for prenatal care visits to include syphilis testing, 11.1% (1/9) provided a teaching event, 11.1% (1/9) described that their facility now retests their pregnant patients after 32 weeks, and 11.1% (1/9) reported no actions taken.