Management of genital chlamydial infections at termination of pregnancy services in England and Wales: where are we now?
Mr D. S. LaMontagne, HIV/STI Department, Health Protection Agency, Communicable Disease Surveillance Centre, 61 Colindale Avenue, London NW9 5EQ, UK.
Objective To determine the range of policies and practices related to the management of genital chlamydial infection employed at termination of pregnancy services in England and Wales.
Design Cross-sectional descriptive study.
Setting England and Wales.
Population Termination of pregnancy providers.
Methods Survey questionnaire administered to termination of pregnancy providers
Main outcome measures Policies and practices for the management of genital chlamydial infection in women seeking termination of pregnancy with comparison to the national guidelines of the chief medical officer (CMO) and the Royal College of Obstetricians and Gynaecologists (RCOG).
Results One hundred and thirty-eight (48%) practices responded to the survey, with representation across England and Wales. Policies for screening and/or treatment of chlamydial infection existed for 70% of providers. We found three practice patterns for the management of genital chlamydial infection among termination of pregnancy attenders: 70% of providers tested their own attenders prior to termination and treated if necessary; about 25% of providers administered prophylaxis without testing; and a small number of providers (<5%) neither tested nor treated attenders.
Conclusion These patterns may be the result of differences in the CMO and RCOG guidelines. Given the impact of untreated genital chlamydial infection in women attending for termination, consistent recommendations from the CMO and RCOG may encourage uniform practice for the management of chlamydial infection in this vulnerable population.
Chlamydia trachomatis is the most common bacterial sexually transmitted infection in England and Wales.1 Untreated infection can lead pelvic inflammatory disease, infertility and ectopic pregnancy.2 Data from termination of pregnancy (TOP) services indicate a prevalence between 4.9% and 14.0% (weighted average prevalence of 7.6%).3–14 In 2001, over 70,000 diagnoses among males and females attending genitourinary medicine (GUM) clinics were recorded, an increase of 158% since 1993.1 Factors associated with infection in these populations include young age (<25 years), non-white ethnicity and presence of other genital tract infections.3,5,15
Around 180,000 medical or surgical terminations of pregnancy (TOP) are performed each year16 and may place women at greater risk of ascending upper genital tract infection.17,18 The incidence of pelvic inflammatory disease in chlamydia-infected women following TOP is between 25% and 63%.17 The chief medical officer's (CMO) Expert Advisory Group on Chlamydia trachomatis has advised screening all women attending for TOP, treatment of those found to be positive and contact tracing of partners for testing and treatment where needed.19 Guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG) allow for either (1) prophylaxis for attenders without testing for chlamydial infection or (2) screening attenders and treatment if indicated.20 There is no mention of partner follow up in the RCOG guidelines. Furthermore, the Department of Health's recent phased roll out of the national Chlamydia Screening Programme recommends opportunistic screening of all women attending for termination of pregnancy, with appropriate treatment and partner notification for women who test positive.21
In this study, we explored current local policy and practice for chlamydia testing and treatment among TOP providers in England and Wales. We examined variations in policy and practice by region of the country, service size and the degree to which the national recommendations regarding testing and treatment for infection have been implemented in termination of pregnancy services.
The most recent (1999) list of termination of pregnancy service providers was obtained from the Department of Health (England) and included the name, location, and annual number of terminations performed for each service. This was used as the sampling frame to identify participating services. All services on the Department of Health list were contacted by telephone to confirm current service provision and to verify contact details.
A survey questionnaire was designed, which requested detail on current policies for screening and treating genital chlamydial infection; assessment of testing and treatment services to client populations; information on follow up for women testing positive; and perceived barriers to implementing chlamydia screening. The survey requested provider practice for those persons attending for surgical termination separately from those persons attending for medical termination. Questionnaires were sent to either the director of gynaecology or the lead clinician at each service with a response paid envelope addressed to the study administrator. A second mailing was sent to non-responders after four weeks. Larger centres (performing more than 100 terminations annually) were contacted directly by telephone two weeks after this to encourage survey completion. The cutoff for responding was 10 weeks after the original mailing.
Data were entered into a secure, password-protected Microsoft Access database. A categorical coding frame for each free text question was developed. Several survey questions were recoded for meaningful analysis. Service size was categorised by the annual number of terminations reported: fewer than 200 terminations per year (small services); 201–600 (medium sized services); or more than 600 annual terminations (large services). Respondents were categorised into either NHS or non-NHS (private and non-specialised combined) services based upon the primary source of funding reported. Data were analysed using SPSS 11.5 (SPSS, Chicago, Illinois) and STATA 7.0 (Stata, College Station, Texas). Descriptive statistics and bivariate analyses with χ2 test (as appropriate) were generated.
Ethical approval for the study was not required as the study was a policy survey related to information at the service and not patient level.
In total, 380 services in England and Wales reported terminations in 1999. Seventy-eight services were excluded due to duplication on the list, service closure, incomplete contact information or changed service mix that no longer included terminations. Eighteen services were excluded as they were represented by the British Pregnancy Advisory Service or Marie Stopes International. As national policies exist for these organisations, one survey questionnaire was sent to the central office of each organisation. In total, 284 services were invited to participate in the study. Responses were acquired from 156 (55%) services. Eighteen providers indicated that they no longer provided a service. Results are presented for 138 services (48% response rate).
All regions except the West Midlands were evenly represented in services of different size (Table 1). One hundred and twenty services (87%) were NHS funded and 16 (12%) were non-NHS funded. Two respondents (1%) did not provide funding information. Eleven respondents reported more than one funding source: eight provided more than 200 terminations funded by the NHS and were classified as such; the other three were classified as non-NHS.
Table 1. Characteristics of 138 services that responded. Values are given as n (%).
|East Midlands||15 (11)|
|North East||11 (8)|
|North West||20 (15)|
|South East||16 (12)|
|South West||18 (13)|
|West Midlands||3 (2)|
|Yorkshire and Humberside||14 (10)|
|Annual number of terminations (n= 135)|
|≤200 (small)||39 (28)|
|201–600 (medium)||48 (35)|
|600 or more (large)||48 (35)|
|Existing policy (n= 136)||96 (70)|
| Testing for genital CT infection||82 (85)|
| Specimen collection and delivery||45 (47)|
| Receipt of laboratory results||50 (52)|
| Treatment of women testing positive||67 (70)|
| Counselling regarding STIs||43 (45)|
| Partner notification||26 (27)|
| Referral to GUM services||65 (68)|
| Treatment of all attenders||14 (15)|
|Surgical terminations||133 (96)†|
|Medical terminations||109 (79)‡|
|Actual screening and treatment practice for CT||Surgical TOP||Medical TOP|
|Neither screens nor treats||3 (2)||5 (5)|
|Prophylaxis without screening||35 (26)||25 (23)|
|Screening and treatment||95 (71)||79 (73)|
Ninety-six services (70%) reported a written policy for screening and/or treatment of genital chlamydial infection. For providers with policies regarding chlamydia screening, the most common content areas within the policy included testing (82/96), treatment (67/96) and referral of positives to GUM clinics (65/96) (Table 1).
Actual practice showed no difference between attenders receiving a medical termination vs those receiving a surgical termination (data not shown). For medical terminations, providers in Yorkshire and Humberside and East Midlands were more likely to employ prophylaxis without testing (P < 0.05). For surgical terminations, services in Yorkshire and Humberside and the North East were more likely to provide prophylaxis without testing (P < 0.05).
NHS services were more likely than non-NHS services to have a screening and/or treatment policy (75%vs 38%, P < 0.05); screen all or some of their surgical termination attenders (74%vs 50%, P < 0.05); and treat all or some of their medical termination attenders (97%vs 71%, P < 0.05). Additionally, NHS services were more likely to report more than 50% of their attenders were screened for chlamydial infection (91%vs 30%, P < 0.05).
Medium and large services were more likely than small services to have a written policy for screening and/or treatment (79%vs 51%, P < 0.05). More small services did not screen women attending for surgical terminations (41%vs 26% [medium] vs 22% [large], P < 0.05). Small services were less likely than medium or large services to telephone test results to women who were screened (12%vs 33%vs 51%, P < 0.05). Small services were also less likely to report a formal policy of onward referral of chlamydia positive patients (50%vs 69% [medium] vs 84% [large], P < 0.05).
Both the RCOG and CMO guidelines recommend screening attenders and treating those who are positive. Over one-third of services administered treatment without screening (Table 1, next to last row). Eighty percent (28/35) of surgical termination providers reported administration of treatment during or after the procedure and 60% of these reported that they administered the RCOG recommended first-line therapy. Medical termination providers, which provided prophylaxis without testing for chlamydial infection, showed a similar pattern of treatment.
Among TOP providers that screen (Table 1, final row), 93% screened all attenders, regardless of surgical or medical termination. Half of the services that screen administered antibiotic treatment for those testing positive (52% and 56% of surgical or medical termination) and half treated all those screened (48% and 44%). Among services that screen for chlamydial infection then treat, if positive, over 90% of providers tested attenders before the termination procedure, regardless of the procedure, and over 80% administered treatment on-site. Treatment mostly occurred during or after termination (70% surgical and 63% medical terminations). Adherence to the RCOG-recommended first-line therapy was reported by 42% of surgical and 48% of medical termination providers.
Very few providers performed partner notification activities themselves (<5%). Approximately half the services (48% of surgical termination providers and 51% of medical termination providers) referred women who test positive onto GUM.
Cervical swabs were used exclusively by over half of screening services, and a combination of swabs and urine was employed by nearly a third, regardless of type of termination procedure. Fewer than 10% of providers were using urine only for specimen collection. Full employment of nucleic acid amplification tests was less than 25%; an additional 50% of providers used only non-amplified tests, such as enzyme immunoassays; and about 20% used a combination of these.
The most common factors reported to limit the delivery of chlamydia testing were lack of financial support (46/138) and time constraints in clinic (38/138). Several service providers stated that prophylactically treating all TOP attenders was easier, more reliable and more cost effective (data not shown).
Our study found significant heterogeneity in the behaviour of termination of pregnancy services in their approach to testing and treating for genital chlamydial infection. Three distinct patterns emerged: (1) TOP providers that screened attenders prior to termination and treated if necessary; (2) providers that administered prophylactic antibiotics without testing; and (3) providers that did not screen or treat. A possible explanation for these patterns might be uncertainty in best practice due to the overlapping and diverging recommendations of the RCOG and the CMO.
Among the nearly 70% of providers that engaged in screening before termination, over 90% tested everyone. The RCOG and CMO guidelines are most similar on this point but the RCOG guidelines do not explicitly recommending testing all patients. Consistency in this policy directive between the two bodies may be warranted. Most screening providers tested prior to termination, as recommended, and collected an appropriate sample. However, less than half were using the more sensitive nucleic acid amplification test that is the current diagnostic standard.21 As TOP providers are likely to become increasingly involved in routine testing for genital chlamydial infection, it is necessary that laboratory capability also improves to provide the best diagnostics for this population.
For all services, differences in the treatment regimen administered were apparent. Inconsistency in the recommended treatment regimens between the RCOG and CMO policies may be influencing these providers' practices. The majority of these providers were in compliance with one guideline or the other, but this lack of explicit and consistent direction for treatment is of some concern. Lack of consistency between guidelines was demonstrated in that about 25% of the providers offered prophylaxis to TOP attenders without testing, a practice that is only encouraged by the RCOG guideline.20 Additionally, less than two-thirds indicated using the RCOG recommended treatment regimen.
Although very few providers reported they neither screened nor treated any TOP attender, the fact that any provider reported this practice is disturbing. There is significant evidence of the health risks associated with untreated genital chlamydial infection17,18 and these risks are much greater for women who have a termination.
Our study has several limitations. Only about one-half of all providers responded to our survey. This is an important source of bias, the direction of which is not possible to predict. Secondly, we do not know to what extent the responses of the central offices for the British Pregnancy Advisory Service and Marie Stopes International represent the practice of providers within their networks. Finally, there may have been practice changes in the intervening years between our survey and this publication, especially in light of the large amount of national coverage for the Department of Health's phased roll out of the national Chlamydia Screening Programme in England.
In conclusion, we found that over 95% of responding TOP providers reported practice consistent with either the RCOG or CMO guidelines on Chlamydia trachomatis, although there were discrepancies. Specifically, guidelines need clarifying on (1) whether antibiotic prophylaxis should be offered to all TOP attenders without testing; (2) what is the appropriate treatment regimen for both prophylaxis without testing and test then treat policies; and (3) what should be the laboratory test standard for all women submitting a sample for chlamydia testing. Additionally, the absence of any guidance regarding partner notification and contact tracing for women testing positive in the RCOG recommendations should be addressed. Synchronising the RCOG and CMO guidelines would be beneficial in harmonising a universal standard for chlamydia testing and treatment for all women, increasing the compliance of providers and may encourage providers to begin a testing programme within their service.
We would like to thank the Department of Health for providing a list of termination services in England and Wales; Maria Solomou for questionnaire administration, data entry and data management; Pauline Rogers for helpful comments on the questionnaire; and Neil Macdonald for questionnaire design wizardry.
D.S.L. analysed and interpreted the data and authored the manuscript. J.M.P. and K.A.F. developed protocol and questionnaire, implemented the study and commented on the manuscript. H.M. and J.H. assisted with protocol and questionnaire development and commented on the manuscript.
Conflict of interest
J.M.P. is currently employed by GlaxoSmithKline but carried out this work while employed by the Health Protection Agency (formerly known as the Public Health Laboratory Service). GlaxoSmithKline was not involved in the decision to publish.