Background. Despite the availability of rapid diagnostic tests and inexpensive treatment for pregnant women, maternal-child syphilis transmission remains a leading cause of perinatal morbidity and mortality in developing countries. In Haiti, more than 3000 babies are born with congenital syphilis annually. Methods and Findings. From 2007 to 2011, we used a sequential time series, multi-intervention study design in fourteen clinics throughout Haiti to improve syphilis testing and treatment in pregnancy. The two primary interventions were the introduction of a rapid point-of-care syphilis test and systems strengthening based on quality improvement (QI) methods. Syphilis testing increased from 91.5% prediagnostic test to 95.9% after ( ) and further increased to 96.8% ( ) after the QI intervention. Despite high rates of testing across all time periods, syphilis treatment lagged behind and only increased from 70.3% to 74.7% after the introduction of rapid tests ( ), but it improved significantly from 70.2% to 84.3% ( ) after the systems strengthening QI intervention. Conclusion. Both point-of-care diagnostic testing and health systems-based quality improvement interventions can improve the delivery of specific evidence-based healthcare interventions to prevent congenital syphilis at scale in Haiti. Improved treatment rates for syphilis were seen only after the use of systems-based quality improvement approaches. 1. Introduction Congenitally acquired syphilis remains a leading cause of perinatal morbidity and mortality in developing countries with an estimated 1.5 million annually affected pregnancies worldwide [1]. In Haiti, studies document that more than 3,000 babies are born with congenital syphilis each year [2]. More than half of these result in still-births or perinatal death [3, 4]. Syphilis is easily detected during antenatal care using rapid test technology for point-of-care diagnosis [5, 6]. Same day treatment can be provided with a single shot of penicillin preventing more than 90% of congenital transmission [3]. Point-of-care diagnosis and same-day treatment can prevent high rates of lost to follow up that occur when treatment is provided at a second visit. Studies in Haiti and Sub-Saharan Africa demonstrate that when treatment is provided at a second visit, nearly fifty percent of women who test positive for syphilis never receive treatment [7]. Point-of-care diagnosis and same-day treatment are inexpensive, and financial analyses in Haiti and elsewhere have demonstrated their cost-effectiveness [8, 9]. Remarkably, same-day care has been known
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