Chapter 5 - VU

Chapter
5
<ŶŽǁůĞĚŐĞĂŶĚĂĐĐĞƉƚĂďŝůŝƚLJŽĨ
ŚůĂŵLJĚŝĂƚƌĂĐŚŽŵĂƟƐƐĐƌĞĞŶŝŶŐ
ĂŵŽŶŐƉƌĞŐŶĂŶƚǁŽŵĞŶĂŶĚƚŚĞŝƌ
ƉĂƌƚŶĞƌƐ͖ĐƌŽƐƐͲƐĞĐƟŽŶĂůƐƚƵĚLJ
DWƵďůŝĐ,ĞĂůƚŚϮϬϭϰ͖ϭϰ;ϭͿ͗ϳϬϰ
Monique T.R. Pereboom
Evelien R. Spelten
Judith Manniën
G. Ingrid J.G. Rours
Servaas A. Morré
François G. Schellevis
Eileen <. ,uƩon
Chapter 5
Abstract
ĂĐŬŐƌŽƵŶĚ͗ ŚůĂŵLJĚŝĂ ƚƌĂĐŚŽŵĂƟƐ inĨecƟons in pregnancLJ can cause maternal
disease, adverse pregnancy outcomes and neonatal disease, which is why chlamydia
screening during pregnancy has been advocated. The eīecƟveness oĨ a screening
program depends on the knowledge of health care professionals, women and
partners and the acceptability for screening of the target populaƟon. te assessed the
knowledge of chlamydia infecƟon among pregnant women and their partners in the
Eetherlands, their aƫtudes towards tesƟng, and their edžperiences of being oīered
a chlamydia test. In addiƟon, we evaluated the associaƟon between parƟcipants͛
background characterisƟcs and knowledge of chlamydia.
DĞƚŚŽĚƐ͗ Pregnant women aged ч ϯϬ years and their partners ;regardless of their
ageͿ aƩending one of the parƟcipaƟng primary midwifery care pracƟces in the
Eetherlands were invited to parƟcipate. All parƟcipants completed a quesƟonnaire,
pregnant women provided a vaginal swab and partners provided a urine sample to
test for ͘ƚƌĂĐŚŽŵĂƟƐ.
ZĞƐƵůƚƐ͗ In total, ϯϴϯ pregnant women and ϮϴϮ partners parƟcipated in the study of
whom ϭ.ϵй women and Ϯ.ϲй partners tested chlamydia posiƟve. ParƟcipants had
high levels of awareness ;ϵϮ.ϴйͿ of chlamydial infecƟon. They were knowledgeable
about the risk of chlamydia infecƟon͖ median knowledge score was ϵ.Ϭ out of ϭϮ.Ϭ.
>ower knowledge scores were found among partners ;pͲvalue фϬ.ϬϬϭͿ, younger aged
;pͲvalue Ϭ.ϬϮͿ, nonͲwestern origin ;pͲvalue фϬ.ϬϬϭͿ, low educaƟonal level ;pͲvalue
фϬ.ϬϬϭͿ, and no history of sedžually transmiƩed infecƟons ;pͲvalue фϬ.ϬϬϭͿ. In total,
78% of respondents indicated that when pregnant women are tested for chlamydia,
their partners should also be tested͖ ϱϰ% believed that all women should rouƟnely
be tested. Pregnant women more oŌen indicated than partners that tesƟng partners
for chlamydial infecƟon was not necessary ;pͲvalue фϬ.ϬϬϭͿ. The maũority of pregnant
women ;ϱϲ.Ϯ%Ϳ and partners ;ϱϵ.Ϯ%Ϳ felt saƟsĮed by being oīered the test during
antenatal care.
ŽŶĐůƵƐŝŽŶ͗ Pregnant women and their partners were knowledgeable about
chlamydial infecƟon, found tesƟng, both pregnant women and their partners, for
chlamydia acceptable and not sƟgmaƟnjing.
ϵϮ
<ŶŽǁůeĚŐe aŶĚ aĐĐeptaďŝůŝtLJ ŽĨ ChůaŵLJĚŝa traĐhŽŵaƟƐ ƐĐreeŶŝŶŐ
aŵŽŶŐ preŐŶaŶt ǁŽŵeŶ aŶĚ theŝr partŶerƐ
ĂĐŬŐƌŽƵŶĚ
ŚůĂŵLJĚŝĂƚƌĂĐŚŽŵĂƟƐ infecƟon in pregnancy can cause maternal disease, adverse
pregnancy outcomes, and neonatal disease (1-5). High chlamydia prevalence rates
have been described among pregnant women varying from ϯ.Ϯ% to 5.ϵ%, with even
higher rates among pregnant teenagers (14%) (1, 6-9). In general, approximately
8Ϭ% of infected women and 5Ϭ% of infected men are asymptomaƟc or minimally
symptomaƟc. Hence, screening is the only means to eīecƟvely idenƟfy infecƟons (Ϯ).
In the Eetherlands pregnant women are rouƟnely tested for HIs, syphilis and
hepaƟƟs , but not for chlamydia (Ϯ, 1Ϭ). InternaƟonal guidelines recommend
universal chlamydia screening during antenatal care or screening of pregnant women
less than 25 years of age (11-15). Studies suggest using either of these approaches
for rouƟne chlamydia screening is cost eīecƟve (6, 16). The utch Health ouncil
has no recommendaƟon speciĮc for pregnant women, but recommends in general
that health care professionals should acƟvely screen for chlamydial infecƟons in
people who are at higher risk (17)͖ the laƩer being young age, Surinamese or AnƟllean
ethnicity, aƩending clinics for STIs, having mulƟple sexual partners, and other risk
factors in combinaƟon with sexual behaviour or symptoms, partners of chlamydia
posiƟve persons, and mothers of chlamydia posiƟve new-borns (17). However, in a
previous study we showed that the decision for utch midwives to oīer chlamydia
tesƟng to pregnant women is based on symptoms rather than on risk factors (18).
Hence, many chlamydial infecƟons will remain undetected.
A key factor for the eīecƟveness of an antenatal chlamydia screening program
is that women and their partners have knowledge about the infecƟon and that
they accept screening (19). Knly few studied the knowledge of chlamydia, aƫtudes
towards chlamydia infecƟon screening and experiences of being oīered a chlamydia
test among pregnant and non-pregnant women, and their partners (20, 21).
The aim of this study was to assess the knowledge of chlamydia infecƟon among
pregnant women and their partners in the Eetherlands and to determine associaƟons
between pregnant women and their partner͛s demographic characterisƟcs and their
knowledge on chlamydia infecƟons. In addiƟon, we assessed their aƫtudes towards
antenatal chlamydia tesƟng and experiences of being oīered a test in antenatal care.
ϵϯ
5
Chapter 5
DĞƚŚŽĚƐ
This study is part of a naƟonal cross-secƟonal study about the prevalence and risk
factors for chlamydia infecƟon in pregnant women and their partners. Primary care
midwifery pracƟces were invited using a sampling method based on the locaƟon
of the pracƟces in the Eetherlands. In total, twenty-two primary midwifery care
pracƟces parƟcipated. Pregnant women were eligible for parƟcipaƟon if they
consulted a midwife in one of the parƟcipaƟng pracƟces between May 2012 and
ecember 201ϯ, were pregnant at the Ɵme of enrolment, had reached the legal age of
consent of 18 years, were younger than ϯ1 years of age, and were able to understand
utch. Partners of women were eligible to parƟcipate if they were present at the Ɵme
their pregnant partner was included, and were able to understand Dutch. Because
chlamydia is more prevalent among younger people, we decided to include only
pregnant women younger than ϯ1 years. There was no age limit for the partners.
The Medical Ethics ommiƩee of the sh hniversity Medical enter Amsterdam,
the Netherlands, approved the study.
ĂƚĂĐŽůůĞĐƟŽŶ
The midwife or pracƟce assistant informed pregnant women and their partners
about the study and invited them to parƟcipate. Eligible pregnant women and
partners signed an informed consent form. They were asked to Įll in a quesƟonnaire,
which contained ϯ7 quesƟons. In addiƟon they were asked to provide a self-collected
sample (e.g. a vaginal swab for women and urine specimen for partners), which was
sent to the laboratory for ͘ƚƌĂĐŚŽŵĂƟƐtesƟng.
The quesƟonnaire was developed to obtain data on demographic characterisƟcs,
knowledge of the infecƟon, and aƫtudes towards tesƟng for chlamydia in antenatal
care. YuesƟons were based on previous studies and the literature (8, 19, 22-24).
YuesƟonnaires were provided with a prepaid return envelope. The informed consent
forms and quesƟonnaires were provided with an unique anonyminjed idenƟĮcaƟon
number. te conducted a small pilot study and conĮrmed the acceptance of this
relaƟvely personal quesƟonnaire among women and their partners. Demographic
characterisƟcs and risk factors were age at the Ɵme of enrolment, highest achieved
level of educaƟon, ethnic origin, urbanisaƟon level, marital status (no partnerͬhaving
a partner, but living alone/married or living with a partner), gravidity (primigravidae
versus mulƟgravidae), planned pregnancy (yes/no) and history of sexually transmiƩed
infecƟons (STI) (yes/no/never been tested). For the analyses we categorinjed some of
ϵϰ
<ŶŽǁůeĚŐe aŶĚ aĐĐeptaďŝůŝtLJ ŽĨ ChůaŵLJĚŝa traĐhŽŵaƟƐ ƐĐreeŶŝŶŐ
aŵŽŶŐ preŐŶaŶt ǁŽŵeŶ aŶĚ theŝr partŶerƐ
the demographic characterisƟcs of the parƟcipants. Age was deĮned as the age at
enrolment and categorinjed into three groups for women͗ ч20 years, 21-25 years, 26ϯ0 years. For partners we used the same age groups as well as an addiƟonal group
of шϯ1 years. Highest achieved level of educaƟon was deĮned into three categories͗
low level of educaƟon (medium- level secondary educaƟon or below), medium
level of educaƟon (higher-level secondary educaƟon or vocaƟonal educaƟon) and
high level of educaƟon (diploma level or university educaƟon). Ethnic origin was
deĮned according to the deĮniƟon used by StaƟsƟcs Netherlands, and categorinjed
into Dutch, other western origin, and non-western origin (25). StaƟsƟcs Netherlands
deĮnes someone to be of non-Dutch origin if at least one of the parents was not
born in the Netherlands. In case the parents were born in two diīerent foreign
countries, the mother͛s country of birth prevailed (25). hrbanisaƟon level was based
on the postal code of the address of the pregnant woman or her partner, straƟĮed
according to ͞area address density͟ (AAD), and dichotominjed into ф2499 addresses/
km2 and >2500 addresses/km2 (26). The number of pregnancies women experienced
was dichotominjed into Įrst and mulƟple pregnancies. In addiƟon, pregnant women
and partners were asked whether they had heard about chlamydia before they
parƟcipated in the study giving three answer opƟons͗ ͞I had heard of chlamydia and
knew it was an STI”, “I had heard of chlamydia, but did not know it was an STI”; or
“I had never heard of chlamydia before”. Regarding knowledge of chlamydia, twelve
quesƟons covered pregnant women͛ and partners͛ knowledge about the infecƟon.
We asked them to indicate which general statements and transmission routes of
the infecƟon were “true” “false” or they “did not know”. We presented pregnant
women and partners with a list of six general statements of which one was false, and
with a list of six transmission routes of the infecƟon, of which three were true and
three were false. <nowledge scores were calculated from the knowledge quesƟons
and each correct answer was given a value of +1, and an incorrect answer or the
͚don͛t know͛ opƟon a value of 0. Therefore the overall knowledge sum score could
vary between 0 and 12. Regarding the aƫtudes towards tesƟng, we asked pregnant
women and partners whether they agreed with one of Įve statements about their
aƫtudes towards tesƟng for chlamydia in pregnant women͗ 1) all women should be
tested; 2) only women at increased risk should be tested; ϯ) only women who want
to be tested should be tested; 4) tesƟng during pregnancy is not necessary; and 5) I
have no opinion about whether or not pregnant women should be tested. In addiƟon,
we asked pregnant women and partners whether or not they thought partners of
pregnant women should also be tested for chlamydia during antenatal care if the
ϵϱ
5
Chapter 5
pregnant woman was tested. Finally, we asked pregnant women and partners
about their experiences for being oīered a chlamydia test during antenatal care by
their midwife. Pregnant women and their partners were asked if they felt saƟsĮed,
surprised, sƟgmaƟnjed, ashamed, and whether the test oīer had an emoƟonal impact
on them. These answers were recorded on a Įve point >ikert scale, graded from 1͗
“strongly agree” to 5: “strongly disagree”. The statements were dichotomized into
two categories: (strongly) agreeing (Likert scale 1-2) with the statement versus neutral
or (strongly) disagreeing (Likert scale ϯ-5) with the statement.
ŚůĂŵLJĚŝĂƚƌĂĐŚŽŵĂƟƐĚĞƚĞĐƟŽŶ
To detect ͘ƚƌĂĐŚŽŵĂƟƐ infecƟon, DNA was isolated from the vaginal swab or urine
specimen by the High Pure PR Template PreparaƟon <it (Roche), and processed
using the new E-IsD cerƟĮed PRESTK -PLUS test (Goĸn Molecular DiagnosƟcs,
Houten, the Netherlands). Pregnant women and their partners received the test
result by mail. Those who tested posiƟve for chlamydia were advised to contact
their general pracƟƟoner for treatment. Midwives received the test results of the
pregnant women, but not of the partners. In the current antenatal care system the
partner is not considered as a midwife͛s client. Therefore, midwives did not receive
the partners͛ test results.
Data from the informed consent forms and the quesƟonnaires were linked with
chlamydia test results using anonymized idenƟĮcaƟon numbers.
Analysis
We calculated frequency distribuƟons for quesƟonnaire items on the separate
knowledge quesƟons and the knowledge score, aƫtudes towards chlamydia tesƟng
in antenatal care and experiences for being oīered a chlamydia test.
We used the Mann-Whitney U test and <ruskal-Wallis test for diīerences in
knowledge scores between subgroups of pregnant women and their partners based
on their characterisƟcs. We used these non-parametric tests because the knowledge
score was not normally distributed. In addiƟon we used X2-test staƟsƟcs to test
for diīerences in knowledge quesƟons between subgroups of pregnant women
and partners, and for diīerences between pregnant women and partners in the
experiences of being oīered a test. For all analyses we used SPSS 20.0 (SPSS inc.,
Chicago, IL).
ϵϲ
<ŶŽǁůeĚŐe aŶĚ aĐĐeptaďŝůŝtLJ ŽĨ ChůaŵLJĚŝa traĐhŽŵaƟƐ ƐĐreeŶŝŶŐ
aŵŽŶŐ preŐŶaŶt ǁŽŵeŶ aŶĚ theŝr partŶerƐ
ZĞƐƵůƚƐ
In total 485 pregnant women from 22 primary midwifery care pracƟces parƟcipated
in this study. Kf them, 102 pregnant women were excluded from analysis: Įve did
not have a unique parƟcipaƟon code, and 97 did not return the quesƟonnaire.
AŌer exclusion, ϯ8ϯ pregnant women remained in the study, of whom 286 partners
parƟcipated. Four partners were excluded from the study because they did not return
the quesƟonnaire, resulƟng in 282 partners included for analyses.
ŚĂƌĂĐƚĞƌŝƐƟĐƐŽĨƚŚĞƉĂƌƟĐŝƉĂŶƚƐ
The median age of the pregnant women was 27 years, range 18 to ϯ0 years. The
median age of the 282 partners was ϯ0 years, range 18 to 49 years. saginal swabs and
urine samples were available from 627 parƟcipants (94.ϯ%), of which 14 (2.2%) tested
posiƟve for chlamydia; seven women (1.9%) and seven partners (2.6%). Two women
tested negaƟve while their partner tested posiƟve. More detailed informaƟon about
background characterisƟcs of the parƟcipants is shown in table 1.
<ŶŽǁůĞĚŐĞŽĨŚůĂŵLJĚŝĂƚƌĂĐŚŽŵĂƟƐŝŶĨĞĐƟŽŶ
In total, 616 (92.8%) pregnant women and their partners had heard about chlamydia
before they parƟcipated in this study and knew that the infecƟon was an STI; 5 (0.8%)
of them had heard of chlamydia but did not know the infecƟon was an STI, and 4ϯ
(6.5%) pregnant women and partners had never heard of chlamydia before they
parƟcipated in this study.
Kf pregnant women and partners, 81 (12.ϯ%) answered all twelve knowledge
quesƟons correctly. The overall median knowledge score was 9 out of a maximum
possible score of 12 (range: 0 to 12); and 17 (2.6%) of them scored 0. Table 1 shows
the median knowledge scores per demographic subgroup.
SigniĮcantly higher knowledge scores were found among the following subgroups:
pregnant women, age ш 21 years, Dutch and other western origins, high educaƟonal
level and a history of STIs. The correct answers on the knowledge quesƟons are
shown in table 2. The median knowledge scores for pregnant women was 9 out of
a possible score of 12 (25th percenƟle 8, 75th percenƟle 11); for partners the median
knowledge score was 9 out of a possible 12 (25th percenƟle 7, 75th percenƟle 10).
In general, pregnant women had more knowledge on both the true and false
statements than partners. SigniĮcant diīerences between pregnant women and
partners in correct answers were found for the statement that chlamydia can be
ϵϳ
5
Chapter 5
Table 1. CharacterisƟcs and median knowledge scores of pregnant women and partners
^ƵďŐƌŽƵƉƐ
ŚůĂŵLJĚŝĂƚƌĂĐŚŽŵĂƟƐ (n с 627)
posiƟve
negaƟve
ParƟcipants (n с 665)
pregnant woman
partner
Age group (n с 665)
ч 20 years
21-25 years
26-ϯ0 years
ш ϯ1 years (partners only)
Ethnic origin (n с 659)
Dutch
other western origins
non-western origins
UrbanisaƟon (n с 655)
ф2499 addresses/km2
>2500 addresses/km2
EducaƟonal level (n с 662)
low
intermediate
high
Marital status (n с ϯ81)
single
partner, but not living together
married or living together
Pregnancy planned (n с ϯ8ϯ)
no
yes
First pregnancy (n с ϯ76)
yes
no
History of STI (n с 654)
no
yes
never been tested
EƵŵďĞƌa;йͿ
DĞĚŝĂŶ
ŬŶŽǁůĞĚŐĞƐĐŽƌĞΎ
14 (2.2)
61ϯ (97.8)
8.0
9.0
ϯ8ϯ (57.6)
282 (42.4)
9.0
9.0
ϯ0 (4.5)
147 (22.1)
ϯ8ϯ (57.6)
105 (15.8)
8.5
9.0
9.0
9.0
492 (74.7)
55 (8.ϯ)
112 (17.0)
9.0
9.0
8.0
529 (80.8)
126 (19.2)
9.0
9.0
119 (18.0)
255 (ϯ8.5)
288 (4ϯ.5)
8.0
9.0
9.0
10 (2.6)
ϯ5 (9.2)
ϯϯ6 (88.2)
9.5
9.0
9.5
100 (26.1)
28ϯ (7ϯ.9)
9.0
10.0
217 (57.7)
159 (42.ϯ)
10.0
9.0
225 (ϯ4.4)
87 (1ϯ.ϯ)
ϯ42 (52.ϯ)
9.0
10.0
9.0
WͲǀĂůƵĞb
ŝīĞƌĞŶĐĞƐŝŶ
ŬŶŽǁůĞĚŐĞƐĐŽƌĞƐ
ƉĞƌƐƵďŐƌŽƵƉ
.15
ф0.001
.02
ф0.001
.8ϯ
ф0.001
.62
.21
.09
ф0.001
ΎDŝŶŝŵƵŵƉŽƐƐŝďůĞƐĐŽƌĞсϬ͖DĂdžŝŵƵŵƉŽƐƐŝďůĞƐĐŽƌĞсϭϮ
a
ĞŶŽŵŝŶĂƚŽƌǀĂƌŝĞƐĚƵĞƚŽŵŝƐƐŝŶŐǀĂƌŝĂďůĞƐ;ďĞƚǁĞĞŶϬĂŶĚϭϭŵŝƐƐŝŶŐƉĞƌŝƚĞŵͿŽƌĚĂƚĂŝƐŽŶůLJ
ĂǀĂŝůĂďůĞĨŽƌƉƌĞŐŶĂŶƚǁŽŵĞŶ͘
b
DĂŶŶͲtŚŝƚŶĞLJhƚĞƐƚĂŶĚ<ƌƵƐŬĂůͲtĂůůŝƐƚĞƐƚ
ϵϴ
<ŶŽǁůeĚŐe aŶĚ aĐĐeptaďŝůŝtLJ ŽĨ ChůaŵLJĚŝa traĐhŽŵaƟƐ ƐĐreeŶŝŶŐ
aŵŽŶŐ preŐŶaŶt ǁŽŵeŶ aŶĚ theŝr partŶerƐ
dĂďůĞϮ͘ Knowledge concerning ŚůĂŵLJĚŝĂƚƌĂĐŚŽŵĂƟƐinfecƟon
<ŶŽǁůĞĚŐĞƐƚĂƚĞŵĞŶƚƐ
'ĞŶĞƌĂůƋƵĞƐƟŽŶƐĂďŽƵƚŚůĂŵLJĚŝĂƚƌĂĐŚŽŵĂƟƐ
True answers
can you infect people without knowing it͍
can chlamydia be cured with medicines͍
can you have chlamydia more than once͍
can chlamydia cause inferƟlity͍
is condom use protecƟve against chlamydia͍
False answers
will you always have symptoms when infected͍
ŚůĂŵLJĚŝĂƚƌĂĐŚŽŵĂƟƐĐĂŶďĞƚƌĂŶƐŵŝƩĞĚďLJ
True answers
genital sexual contact with an infected person
anal sexual contact with an infected person
oral sexual contact with an infected person
False answers
kissing an infected person on the mouth
a toilet seat
sharing bath towels with an infected person
WƌĞŐŶĂŶƚ
women
;ŶсϯϴϯͿ
E;йͿ
Partners
;ŶсϮϴϮͿ
E;йͿ
WͲǀĂůƵĞa
ϯϯ6 (88.2)
ϯ40 (89.2)
256 (67.2)
280 (7ϯ.5)
ϯ00 (78.7)
2ϯ6 (84.0)
221 (78.6)
16ϯ (58.0)
181 (64.4)
216 (76.9)
.15
ф0.001
.02
.02
.6ϯ
ϯ25 (85.ϯ)
201 (71.5)
ф0.001
ϯ49 (91.8)
246 (64.7)
212 (55.8)
250 (89.0)
169 (60.4)
146 (52.1)
.26
.29
.40
290 (76.ϯ)
241 (6ϯ.4)
218 (57.4)
196 (70.0)
154 (54.8)
1ϯ5 (48.0)
.08
.0ϯ
.02
5
a
ŚŝƐƋƵĂƌĞƚĞƐƚ
cured by medicines (89.2% of pregnant women versus 78.6% of partners); that you
can have a chlamydia infecƟon more than once (67.2% of pregnant women versus
58.0% of partners); and that chlamydia can cause inferƟlity (7ϯ.5% of pregnant women
versus 64.4% of partners). In addiƟon, pregnant women indicated signiĮcantly more
oŌen correctly “no” to the statement that you always have symptoms when you are
infected (85.ϯ% of pregnant women versus 71.5% of partners). Pregnant women and
partners were aware that chlamydia infecƟons can be transmiƩed by genital sexual
contact with an infected person.
Pregnant women signiĮcantly more oŌen correctly indicated that you cannot get
infected with chlamydia through toilet seats (6ϯ.4) than partners (54.8%). In addiƟon,
women indicated signiĮcantly more oŌen correctly that one cannot get infected with
chlamydia through bath towels (57.4%) than partners (48.0%).
ƫƚƵĚĞƐƚŽǁĂƌĚƐƚĞƐƟŶŐ
According to ϯ47 (54.2%) parƟcipaƟng pregnant women and partners, all women
should rouƟnely be tested for chlamydia in antenatal care; 85 (1ϯ.ϯ%) reported that
ϵϵ
Chapter 5
Table 3. Aƫtudes towards ŚůĂŵLJĚŝĂƚƌĂĐŚŽŵĂƟƐ tesƟng during antenatal care
ƫƚƵĚĞƐƚŽǁĂƌĚƐĐŚůĂŵLJĚŝĂůƚĞƐƟŶŐ
all pregnant women should be tested
only pregnant women at increased risk
only pregnant woman who want to be tested
tesƟng pregnant women is not necessary
no opinion
WƌĞŐŶĂŶƚ
women
;ŶсϯϲϴͿ
E;йͿ
206 (56.0)
61 (16.6)
8ϯ (22.6)
0 (0.0)
18 (4.9)
Partners
;ŶсϮϳϮͿ
E;йͿ
WͲǀĂůƵĞa
141 (51.8)
24 (8.8)
77 (28.ϯ)
1 (0.4)
29 (10.7)
.ϯ4
.01
.12
.88
.01
a
ŚŝͲƐƋƵĂƌĞƚĞƐƚ
Table 4. Experiences of being oīered a ŚůĂŵLJĚŝĂƚƌĂĐŚŽŵĂƟƐ test during antenatal care
Experiences
WĂƌƚŶĞƌƐǁŚŽĂŐƌĞĞĂ
;ŶсϮϳϰͿ
E;йͿ
I felt saƟsĮed with the test oīer
WƌĞŐŶĂŶƚǁŽŵĞŶǁŚŽ
ĂŐƌĞĞa
;ŶсϯϳϲͿ
E;йͿ
221 (59.2)
I felt surprised by the test oīer
57 (15.2)
48 (17.5)
7 (1.8)
10 (ϯ.7)
I felt sƟgmaƟsed by the test oīer
I felt ashamed by the test oīer
The test oīer had no emoƟonal impact on me
a
154 (56.2)
10 (2.7)
ϯ (1.1)
265 (70.5)
191 (69.7)
WĞƌĐĞŶƚĂŐĞŽĨƉƌĞŐŶĂŶƚǁŽŵĞŶĂŶĚƉĂƌƚŶĞƌƐǁŚŽƐƚƌŽŶŐůLJĂŐƌĞĞŽƌĂŐƌĞĞǁŝƚŚƚŚĞƐƚĂƚĞŵĞŶƚ
only women at increased risk should be tested; 160 (25.0%) reported that pregnant
women should only be tested if they want to be tested, one persons reported that
tesƟng pregnant women for chlamydia was not necessary, and 47 (7.ϯ%) reported
that they had no opinion about whether or not pregnant women should be tested
for chlamydia in antenatal care. Table ϯ shows the diīerences in aƫtudes between
pregnant women and partners towards tesƟng pregnant women for chlamydia.
Compared to the pregnant women, partners were less likely to report that only
pregnant women at increased risk should be tested for chlamydia (8.8% partners
versus 16.6% pregnant women) and partners were more likely to have no opinion
whether or not pregnant women should be tested for chlamydia during pregnancy
(10.7% partners versus 4.9% pregnant women). In addiƟon, 512 (78.ϯ%) of the
parƟcipants indicated that the partners should also be tested for chlamydia during
pregnancy if the pregnant woman was tested; 48 (7.ϯ%) indicated it was not
necessary to test also the partner, and 94 (14.4%) did not have an opinion about
whether partners of pregnant women should be tested. Compared to the partners,
pregnant women indicated more oŌen that tesƟng partners for chlamydia during
pregnancy was not necessary (10.8% of pregnant women versus 2.6% of partners,
ϭϬϬ
<ŶŽǁůeĚŐe aŶĚ aĐĐeptaďŝůŝtLJ ŽĨ ChůaŵLJĚŝa traĐhŽŵaƟƐ ƐĐreeŶŝŶŐ
aŵŽŶŐ preŐŶaŶt ǁŽŵeŶ aŶĚ theŝr partŶerƐ
p-value ф0.001). Partners indicated more oŌen than pregnant women that they
did not have an opinion about the statement that it is necessary to test partners
of pregnant women for chlamydia during antenatal care (10.ϯ% of pregnant women
versus 20.1% of partners, p-value 0.001).
džƉĞƌŝĞŶĐĞƐŽĨďĞŝŶŐŽīĞƌĞĚĂƚĞƐƚ
The maũority of pregnant women (59.2%) and partners (56.2%) felt saƟsĮed with the
test oīer for chlamydia, and for most pregnant women (70.5%) and partners (69.7%) it
had no emoƟonal impact. In total, ϯ.7% of the pregnant women and 1.8% of partners
felt sƟgmaƟzed by having a chlamydia test oīered, and 2.7% of the pregnant women
and 1.1% of the partners felt ashamed by having a test oīered.
ŝƐĐƵƐƐŝŽŶ
This study shows that pregnant women and their partners think that tesƟng women
for chlamydia during antenatal care is acceptable and not sƟgmaƟzing.
To our knowledge there are not many studies in industrialized country that
tested both pregnant women and partners for chlamydia infecƟon during antenatal
care, as well as that we assessed their aƫtudes towards tesƟng and experiences of
being oīered a test. We found posiƟve aƫtudes towards screening. However, it is
possible that partners of pregnant women who did not parƟcipate in this study were
less posiƟve about being tested for chlamydia infecƟon during antenatal care. Some
bias may have occurred in this study. We cannot comment on the characterisƟcs
or reasons for not parƟcipaƟng since the number and reasons for refusal for both
pregnant women and their partners were not recorded. Furthermore, midwives
may not have asked all eligible pregnant women to parƟcipate. Possible explanaƟons
may be Ɵme constraints or because midwives felt uncomfortable asking pregnant
women to parƟcipate in a chlamydia study. In our previous study we have shown
that midwives are oŌen not comfortable asking pregnant women about their sexual
history. Likewise, they may feel uncomfortable inviƟng women and partners to
parƟcipate in a chlamydia prevalence study (18). In addiƟon, 20% of pregnant women
did not return the quesƟonnaire. It is possible that the women and partners did not
have the commitment to parƟcipate, but also that they did not know the answers to
the quesƟons and therefore not returned the quesƟonnaire. Furthermore, pregnant
women and partners completed the quesƟonnaire at home and may have searched
the Internet for correct answers on the knowledge quesƟons. These facts may have
ϭϬϭ
5
Chapter 5
led to an overesƟmaƟon of the knowledge scores and an overopƟmisƟc view on
screening for chlamydia in pregnancy and explain the diīerences with other studies
among pregnant women and non-pregnant young women in which lower awareness
levels and knowledge scores for chlamydia infecƟon were found (20, 27). In addiƟon,
our respondents were higher educated than the general Dutch populaƟon. This may
also explain why we found lower prevalence rates of chlamydia in pregnant women
compared with previous studies.
Unfortunately, we did not invesƟgate the aƫtudes and experiences of pregnant
women and partners aŌer they received their chlamydia test result. A posiƟve test
result may inŇuence their future aƫtudes or experiences (28). However, studies from
Australia showed that chlamydia infected women, both pregnant and non-pregnant,
did not diīer from uninfected women concerning their aƫtudes towards tesƟng, and
most of them felt relieved and grateful that chlamydia was diagnosed and treated
(20, 28). TesƟng might be acceptable for pregnant women as they could undertake
whatever care is necessary to ensure the health of their baby (20).
The majority of the pregnant women and their partners included in this study
were aware about chlamydia being an STI, unlike the study among pregnant women
in Australia (20). Again, these results may be an overesƟmaƟon of the actual level
of awareness among pregnant women and their partners, as the correct answer
was given as one of the answer opƟons. Kur results show diīerences in knowledge
scores between certain subgroups of parƟcipants. Lower knowledge scores were
found among partners, pregnant women and partners aged 21 years and younger,
pregnant women and partners of non-western origin and pregnant women and
partners with a low educaƟonal level. These Įndings are indirectly comparable with
the diīerenƟal uptake of chlamydia screening programs in the general populaƟon, as
these subgroups oŌen have lower parƟcipaƟon rates (29). This is important, as these
subgroups are also at higher risk for chlamydia infecƟon (1, 8, 20).
Kur study found that pregnant women and their partners had posiƟve aƫtudes
towards antenatal chlamydia tesƟng. Although one quarter of the pregnant women
and partners indicated that pregnant women should only be tested if they want
to be tested, the majority indicated that all pregnant women should be tested for
chlamydia. This indicates high acceptance of tesƟng for chlamydia during antenatal
care. Furthermore, the majority of parƟcipants indicated that the partner of a
pregnant woman should also be tested for chlamydia infecƟon during antenatal
care. These results are comparable with a study from Sweden in which most of the
ϭϬϮ
<ŶŽǁůeĚŐe aŶĚ aĐĐeptaďŝůŝtLJ ŽĨ ChůaŵLJĚŝa traĐhŽŵaƟƐ ƐĐreeŶŝŶŐ
aŵŽŶŐ preŐŶaŶt ǁŽŵeŶ aŶĚ theŝr partŶerƐ
interviewed men showed posiƟve aƫtudes towards tesƟng for HIs and chlamydia
during antenatal care and that this would make them feel more involved in the
pregnancy (ϯ0). This may also explain that partners indicated more oŌen than
pregnant women that tesƟng the partners for chlamydia during pregnancy was
necessary. Partners are oŌen seen as a psychosocial support for the pregnant
woman, but the biological health risks of transmiƫng an STI to the women and their
unborn oīspring are usually neglected (ϯ0). TesƟng partners for chlamydia may be
important, as a Dutch study among asymptomaƟc couples showed that at one Ɵmepoint only half of the partners were infected (ϯ1). Hence, it may be possible that a
woman tests negaƟve for chlamydia during the Įrst trimester of pregnancy while
her partner has a chlamydia infecƟon, which occurred twice in our study. In that
case the pregnant women might get infected by her partner later during pregnancy.
Midwives in the Netherlands provide only care to pregnant women and not to their
partners. However, women and partners showed posiƟve aƫtudes towards partner
tesƟng during pregnancy, which may oīer an opportunity to add this screening to
the midwifery scope of pracƟce or to arrange for tesƟng by a general pracƟƟoner or
an STI clinic.
The majority of pregnant women and partners felt saƟsĮed when they were
oīered a chlamydia test. Knly a small proporƟon felt sƟgmaƟzed or ashamed
when the midwife oīered them a test. For midwives it is necessary to minimize
embarrassment by oīering clients appropriate informaƟon on chlamydia infecƟon.
In the Netherlands, target screening for chlamydia is recommended by the Dutch
Health Council (17). However, target screening has the potenƟal to sƟgmaƟze people,
and midwives may not feel comfortable in asking their clients quesƟons about sexual
behaviours (18). In addiƟon, Dutch midwives usually base their decision to oīer
pregnant women a chlamydia test on symptoms of the disease (18). Hence, many
cases of chlamydia remain undetected and untreated, as chlamydial infecƟon causes
symptoms in only 20% of women (2). RouƟne screening of all pregnant women will
prevent sƟgmaƟzaƟon. A study that esƟmated the cost-eīecƟveness of chlamydia
screening among Dutch women revealed that screening women for chlamydia during
pregnancy is cost-eīecƟve in the Netherlands (16). Moreover, pregnant women are
oŌen highly moƟvated to accept chlamydia tesƟng during antenatal care, as they are
willing to undertake whatever care is necessary to ensure the health of their oīspring
(20).
ϭϬϯ
5
Chapter 5
ŽŶĐůƵƐŝŽŶ
This study showed that pregnant women and their partners were knowledgeable
about chlamydia infecƟon and that tesƟng was highly acceptable and not sƟgmaƟzing.
These results provide a good basis for introducing a chlamydia screening programme
during pregnancy in the Netherlands. Since chlamydia can be easily treated, such
program would lower transmission of chlamydia, maternal disease, adverse pregnancy
outcomes and neonatal disease.
ŽŵƉĞƟŶŐŝŶƚĞƌĞƐƚƐ
The authors declare to have no compeƟng interests.
ƵƚŚŽƌ͛ƐĐŽŶƚƌŝďƵƟŽŶƐ
MTRP, JM, ERS, FGS and EKH developed the study protocol. MTRP, JM, ERS, GIJGR,
SAM, FGS and EKH developed the quesƟonnaire for pregnant women and partners.
MTRP collected the data and was responsible of data linkage of the data sources.
SAM analysed the ͘ƚƌĂĐŚŽŵĂƟƐ samples. MTRP, JM, ERS, GIJGR, SAM, FGS and EKH
supported the data analyses. All authors contributed to the ediƟng of the manuscript
and have reviewed and approved the Įnal version.
ĐŬŶŽǁůĞĚŐĞŵĞŶƚƐ
The authors would like to thank all parƟcipaƟng midwifery care pracƟces,
pregnant women and partners. We thank Roel Heijmans (technician, Laboratory of
ImunogeneƟcs, sUmc, Amsterdam, the Netherlands) for ͘ ƚƌĂĐŚŽŵĂƟƐ detecƟon.
The study was funded by the Academy of Midwifery Amsterdam-Groningen (AVAG),
the Netherlands.
ϭϬϰ