Low chlamydia testing uptake among young pregnant women in Australia highlights the need for national leadership in this area

In this edition of ANZJOG, Li et al. report the results of a recent survey of obstetricians that found only 21% of those surveyed reported offering universal chlamydia screening to pregnant women <25 years of age, despite the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) recommendation to test pregnant women <25 years of age. This survey was based on self-report, however, and without surveillance of chlamydia testing data during pregnancy, it is difficult to be certain what the true screening rate is. Chlamydia is a significant public health problem in Australia. Diagnosis rates have increased steadily from 87.2 per 100,000 in 2000 to 363.6 per 100,000 in 2012, with over 82,000 cases diagnosed in 2012. Over two-thirds of diagnoses among women are in those under 25 years, and a population-based study conducted in 2003–2004 found a prevalence of 4% among 18–25-year-old women who had ever had sex. A recent meta-analysis of Australian data reported a high prevalence among young pregnant women (<25 years) ranging from 4.5 to 22.0%. The survey by Li et al. would have benefited by including clinicians at pregnancy termination services because a review of prevalence data over the years from a major maternity hospital in Australia has shown this group to also have high rates of chlamydia. While there is much debate internationally about the effectiveness of annual chlamydia testing for reducing the prevalence of chlamydia and the risk of complications such as PID arising from infection, recent data from a wellconducted cohort study in the Netherlands have shown increased odds of preterm delivery in women infected with chlamydia. In this cohort of over 3,900 pregnant women, specimens were collected for chlamydia testing during an antenatal visit in early pregnancy (gestational age <18 weeks). Chlamydia was detected in 3.9% women, and in the absence of guidelines recommending chlamydia testing and treatment during pregnancy in the Netherlands, the researchers were able to avoid treating those testing positive for chlamydia. After adjustment for potential confounders, chlamydia carriage was significantly associated with preterm delivery before 32 weeks (OR = 4.4; 95% CI: 1.3, 15.2) and 35 weeks gestation (OR = 2.7; 95% CI: 1.1, 6.5), but no association was observed with low birthweight. Of all deliveries before 32 and 35 weeks gestation, 14.9% (95% CI 4.5, 39.5) and 7.4% (95% CI 2.5, 20.1), respectively, were attributable to chlamydia infection. So if we were to assume that the association between chlamydia and preterm delivery observed in this study was causal, then testing and treating chlamydia during pregnancy could lead to a 15% reduction in preterm deliveries before 32 weeks. A testing rate of about 21% for pregnant women is not surprising given that chlamydia testing rates in general are low in Australia (about 10% in women), even though testing is much easier today with the advent of molecular diagnostics. Previously, appropriate swabs from columnar epithelial cells from the endocervical canal were required for culture, which was often unpleasant for the woman and a barrier to testing. However, with the high sensitivity of polymerase chain reaction technology, urine specimens or self-collected vaginal swabs have been found to be as sensitive as clinician collected endocervical swabs, hence making chlamydia testing during pregnancy much easier. There is considerable inconsistency of chlamydia testing guidelines across Australia, which does not help healthcare providers. Li et al. identified a total of 17 state/territory and national policy and guideline documents relating to chlamydia testing, but of these, only six made reference to testing during pregnancy and they all varied somewhat in their recommendations. At the national level, RANZCOG recommends ‘selective testing’ for chlamydia for those who may be at increased risk (eg: <25 years). However, this is very ambiguous – what is ‘selective testing’? The Royal Australian College of General Practitioners (RACGP) in their Guidelines for Preventive Activities in General Practice (Red Book) recommend all pregnant women at risk should be tested for chlamydia, although they do not define ‘at risk’. A subsequent edition of the Red Book (8th edition) was published in late 2012 and now recommends that 15–29-year-old people should have a chlamydia test every 12 months, placing further uncertainty about testing guidelines during pregnancy and whether ‘at risk’ should now be considered in women under 30 years of age. Contact tracing or partner notification is not explicitly covered in any of the policy or guideline documents with regards to pregnancy; yet given that over 20% of young women infected with chlamydia will get re-infected within the next 12 months, and re-infection increases a woman’s risk of further complications associated with chlamydia, effective treatment of sexual partners is vital to reduce the risk of re-infection and should be included in any testing recommendation. The findings from Li et al. show that 1) chlamydia testing among pregnant women in Australia is low; 2) the varied approaches to chlamydia testing in hospitals reflect the lack of national policy leadership in the area, and; 3) there is considerable inconsistency with chlamydia testing guidelines for pregnant women, making it difficult for those providing obstetric care. Given the relatively high prevalence of chlamydia among young women, the ease