Abstract
Background:
Congenital syphilis (CS) is a preventable yet persistent public health problem in the United States. Maternal mental health conditions (MMHC) during pregnancy may contribute to missed prevention opportunities, but their association with CS outcomes is unclear.
Methods:
Georgia sexually transmitted infections (STI) surveillance data (2018–2023) were analyzed to assess pre-birth MMHC mentions among syphilis-affected pregnancies, their association with CS, and variation by maternal household composition as a proxy for immediate social support. MMHC mentions were identified using rule-based analysis of free-text case narratives from year before delivery. Modified Poisson regression was used to estimate adjusted prevalence ratios (aPR), and an internal validation substudy informed probabilistic bias adjustment for MMHC misclassification.
Results:
Among 1,684 syphilis-affected pregnancies, 416 (25%) resulted in CS. Pre-birth MMHC were documented in 4% and were associated with higher CS prevalence (aPR 1.5 [95% CI:1.1–2.1]). Although the association did not differ significantly by maternal household composition, it was attenuated among women living with family or partners (aPR 1.18 [95% CI: 0.57–2.47]) compared with those living alone or with non-family members (aPR 1.42 [95% CI: 0.70–2.90]). Internal validation indicated MMHC under-ascertainment in surveillance data; bias-adjusted analyses suggested a stronger association with CS, albeit with considerable uncertainty (bias-adjusted PR 2.1, 95% simulation interval 0.8–5.0).
Conclusions:
Pre-birth MMHC mentions captured during STI case investigations were associated with increased CS prevalence and may serve as an early indicator of vulnerability. Incorporating mental health-informed follow-up into STI surveillance workflows could enhance care coordination and strengthen CS prevention.
SHORT SUMMARY
Maternal mental health concerns documented during syphilis case investigations were associated with higher congenital syphilis prevalence and delayed prenatal care, highlighting opportunities for enhanced follow-up and strengthened prevention efforts.
INTRODUCTION
Despite well-established screening practices and widespread availability of effective treatment for syphilis in the United States (US), congenital syphilis (CS) – a preventable infection transmitted from mother to infant during pregnancy – remains a major and worsening public health challenge.1–5 Over the past decade, reported CS cases in the US increased nearly eight-fold, with incidence rates rising from 12 in 2014 to 110 per 100,000 births in 2024.6,7 This increase has paralleled rising syphilis diagnoses among women of reproductive age and reflects persistent gaps in timely detection and treatment during pregnancy, despite available prevention tools.8
These gaps have been well characterized as missed opportunities for CS prevention. A recent national assessment estimated that nearly 90% of CS cases were directly attributable to such gaps, highlighting the central role of effective healthcare engagement during pregnancy in preventing newborn infection.9 Underlying these missed opportunities is a complex interplay of individual- and system-level factors, including substance use disorders, low socioeconomic status, lack of insurance, housing instability, and experiences of domestic or sexual violence, that impede timely access to prenatal care necessary for early detection and sustained engagement in adequate treatment.8,10–12
A potentially important but understudied contributor to missed opportunities for CS prevention is maternal mental health. Mental health disorders, including mood, anxiety, and psychotic conditions, have been theorized to shape engagement with healthcare across various chronic and infectious conditions by influencing health beliefs, amplifying perceived barriers, and diminishing self-efficacy.13–17 Symptoms such as impaired motivation, poor concentration, emotional distress, and pessimism often co-occur during mental health episodes and may further contribute to inconsistent care engagement.17 Empirical studies have also linked these conditions to measurable declines in healthcare engagement, including missed appointments, delayed treatment initiation, and reduced adherence to medical recommendations.18,19 During pregnancy, such disruptions may be particularly consequential, as timely prenatal care and treatment adherence are critical for preventing adverse outcomes, including CS.
Pregnancy, a period of substantial hormonal and psychosocial change, represents a time of heightened vulnerability to mental health challenges. National surveillance data indicate that approximately one in five mothers experience a mental health condition, and these conditions currently constitute the leading underlying cause of pregnancy-related mortality in the US.20–22 In this context, receipt of a sexually transmitted infection (STI) diagnosis, which may provoke shame, isolation, and fear of rejection, can further exacerbate psychological distress, compounding vulnerabilities where they already exist.23–26 Together, these observations suggest that maternal mental health among women diagnosed with syphilis may represent an important determinant of missed opportunities for CS prevention, shaping healthcare engagement, timely screening, and treatment during pregnancy and, ultimately, the risk of congenital infection.
Among pregnant women with syphilis, social support may play a key role in mitigating the psychological and practical barriers that interfere with timely care. Emotional, instrumental, informational, and appraisal support from partners, family, and broader social networks can buffer psychological stress, enhance coping, and facilitate healthcare engagement, potentially helping affected women overcome challenges associated with mental health concerns.27,28 Evidence further suggests that the protective effect of social support varies by recipient’s life stage and support source. A systematic review found that parental and family support were most protective against depression in children and adolescents, while spousal and friend support were most salient in older adults; among adults of childbearing age, partner and family support had the strongest protective effect, followed by friend support.29 These findings suggest that, among pregnant women with syphilis, the protective impact of social support may likewise vary by source, with implications for reducing the risk of congenital infection.
Despite evidence linking maternal mental health to healthcare engagement, little empirical evidence exists on its influence on CS outcomes among women with syphilis-affected pregnancies (SyAPs), particularly in high-burden regions such as the southern United States including Georgia.30,31 Using surveillance data, we assessed the prevalence of documented maternal mental health conditions (MMHC) among women with SyAPs and examined their association with CS outcomes and variation by likely sources of support within the mother’s immediate environment. Understanding how maternal mental health affects CS outcome may help inform interventions to avert missed opportunities for CS prevention and reduce the burden of congenital syphilis.
METHODS
Data Source, Study Eligibility and Ethics Statement
Data on diagnosed syphilitic infections were obtained from the Georgia State Electronic Notifiable Diseases Surveillance System (SENDSS), a statewide repository of reportable diseases.32 Females diagnosed with syphilis (any stage) between January 1, 2018, and December 31, 2023, were included if documented as pregnant at the time of diagnosis. To identify all women with SyAPs within the period, SENDSS data were linked to live birth and fetal death records from the Georgia Vital Events and Records System (GAVERS) for January 1, 2018, through December 31, 2024 using probabilistic record matching. Females with a syphilis diagnosis but without documented pregnancy status in SENDSS were also classified as having a SyAP if a confirmed birth was recorded in GAVERS within 30 days before or 280 days after the diagnosis date. Females recorded as pregnant in SENDSS but lacking corresponding birth record in SENDSS or GAVERS were excluded. The final cohort of SyAPs was subsequently linked to the CS registry in SENDSS (2018–2024) to ascertain outcomes, including CS live births and syphilitic stillbirths.
The study was approved by the Georgia Department of Public Health Institutional Review Board, and informed consent was waived due to the use of de-identified data (Project 250402). All procedures were conducted in accordance with applicable state and federal laws, and institutional ethical standards.
Exposure and Outcome Measures
The exposure of interest was MMHC during pregnancy (pre-birth). In the absence of a structured mental health field in SENDSS, MMHCs were identified from mental health-related information in unstructured text sources within SENDSS, including field investigation narratives, interview records, and other free-text documentation generated during syphilis case investigations. Free-text notes were first tokenized into sentences in R (version 4.2.0). Sentences were then searched using a manually developed, rule-based approach to flag terms reflecting mental health diagnoses, symptoms, or service utilization during maternal syphilis investigations (Appendix A1). Flagged notes were manually reviewed for misclassifications, and identified mentions were aggregated across records to assign MMHC status for each SyAP. MMHC mentions were classified relative to the eventual birth event using system-recorded timestamps on case narratives. Mentions occurring within the year prior to delivery were considered pre-birth MMHC mentions, whereas those only documented outside that window were excluded.
The primary outcome was any CS event, defined as a probable or confirmed case in a live birth according to the 2018 Council of State and Territorial Epidemiologists (CSTE) case definitions or as a syphilitic stillbirth.33
Covariate Measures
Covariates included in inferential analyses were selected based on a directed acyclic graph (DAG; Figure S1) and comprised maternal age, race/ethnicity, HIV status, experience of violence (domestic or sexual), area-level socioeconomic status, and living environment vulnerability. Area-level socioeconomic status was measured as the proportion of families living below the federal poverty level in the maternal census tract and dichotomized as ≤10% versus >10%. Maternal living environment vulnerability was assessed using Theme 4 (housing type and transportation availability) of the CDC 2022 Social Vulnerability Index (SVI), linked to surveillance data via maternal census tract.34 Additional covariates included maternal history of reported drug use, prenatal care receipt, and county-level urbanicity, classified according to the CDC 2023 National Center for Health Statistics urban–rural scheme (large urban, large suburban, small or medium metropolitan, or rural).35
Social Support Source
Household composition data collected during syphilis case investigations were used to characterize likely sources of in-home social support within the mother’s immediate environment. Responses describing whom the mother lived with at the time of investigation were used to categorize participants into three groups: 1). those living with a partner (e.g., father of the baby, spouse, or boyfriend) or family members (biologic relatives of the mother or infant); 2). those living alone (including living with children only) or with non-family members (e.g., co-worker, neighbors, friends, godparents, homeless or correctional facility co-residents); and 3). those with unknown household composition.
Statistical Analysis
Cohort characteristics were summarized using frequencies and percentages, and temporal trends were assessed using the Cochran-Armitage test for trend. The prevalence of pre-birth MMHC mentions was estimated, and correlates of MMHC mention in STI surveillance records were evaluated using multivariable logistic regression.
Associations between pre-birth MMHC mentions and CS outcomes were examined using modified Poisson regression (robust error variance) to estimate adjusted prevalence ratios (aPR). Models were adjusted for DAG-identified confounders, including maternal age, race/ethnicity, HIV status, violence experience, census tract-level poverty, and SVI theme 4. Heterogeneity by race/ethnicity, urbanicity, and area-level socioeconomic status was assessed using stratified analyses and likelihood ratio tests. Effect modification by social support source was evaluated by including cross-product terms between pre-birth MMHC mentions and support source, with statistical significance assessed using likelihood ratio tests.
Given that MMHC status was ascertained from surveillance data, an internal validation substudy using medical chart review was conducted to assess misclassification (Appendix A2). An enriched validation sample was constructed by including all SyAPs with pre-birth MMHC documentation in surveillance records and a random sample of 100 women without mentions. Medical charts were abstracted by three reviewers, blinded to surveillance-based MMHC status, to identify documented mental health diagnoses, symptoms, or services received in the year before delivery. Using chart-derived pre-birth MMHC status as reference standard, positive and negative predictive values (PPV and NPV) of surveillance-based MMHC classification were estimated for cases (SyAPs resulting in CS events) and non-cases.36 PPV was defined as the proportion of surveillance-based MMHC mentions confirmed in medical records, and NPV as the proportion without surveillance-based MMHC documentation who also lacked such documentation in reviewed charts.
PPV estimates were then incorporated into a probabilistic bias analysis to adjust effect estimates for MMHC misclassification (Appendix A3). All statistical tests were two-sided with a significance level of 0.05. Analyses were conducted using R version 4.2.0.
RESULTS
Sample Description
Among 8,019 females diagnosed with syphilis during 2018–2023, 1,708 (21%) were pregnant. Twenty-four lacked documented birth information and were excluded, yielding a final analytic cohort of 1,684 SyAPs (Table 1). Most were non-Hispanic Black (65%), followed by non-Hispanic White (21%), Hispanic (11%), and other or multiple races, non-Hispanic (2%). Nearly two thirds (63%) were aged <30 years, and 72% resided in large suburban or small-to-medium metropolitan counties. Reported drug use occurred in 20%, and 24% had no or unknown prenatal care. From 2018 to 2023 (Table S1), the proportion of SyAPs reporting drug use increased from 16% to 25% (p=0.003), and the proportion with no or unknown prenatal care increased from 26% to 30% (p=0.016).
Table 1.
Characteristics of Pregnant Women with Diagnosed Syphilitic Infections, Georgia (2018 – 2023)
| Total | Had Pre-Birth MMHC Mention | No Pre-Birth MMHC Mention | p-value | |
|---|---|---|---|---|
| Characteristics | n (column %) | n (column %) | n (column %) | |
| N | 1684 | 67 | 1617 | |
| Age (years): Median (Q1, Q3) | 26 (22, 30) | 26 (22, 31) | 26 (22, 30) | 0.58 |
| Age Categories (years) | 0.12 | |||
| <20 | 162 (10%) | 10 (15%) | 152 (9%) | |
| 20–24 | 516 (31%) | 15 (22%) | 501 (31%) | |
| 25–29 | 546 (32%) | 18 (27%) | 528 (33%) | |
| 30–34 | 302 (18%) | 18 (27%) | 284 (18%) | |
| 35 plus | 158 (9%) | 6 (9%) | 152 (9%) | |
| Race/Ethnicity* | 0.15 | |||
| Black, non-Hispanic | 1101 (66%) | 51 (76%) | 1050 (65%) | |
| Hispanic, all races | 179 (11%) | 2 (3%) | 177 (11%) | |
| Other or multiple races, non-Hispanic | 40 (2%) | 1 (1%) | 39 (2%) | |
| White, non-Hispanic | 358 (21%) | 13 (19%) | 345 (21%) | |
| Syphilitic Infection Stage | 0.80 | |||
| Primary or Secondary | 237 (14%) | 11 (16%) | 226 (14%) | |
| ENPNSa | 382 (23%) | 16 (24%) | 366 (23%) | |
| Late Latent/Unknown Duration | 1065 (63%) | 40 (60%) | 1025 (63%) | |
| HIV Status | <0.001 | |||
| Known Positive | 26 (2%) | 5 (7%) | 21 (1%) | |
| Not a Known Positive | 1658 (98%) | 62 (93%) | 1596 (99%) | |
| Reported Domestic/Sexual Violence Experience | <0.001 | |||
| No | 1642 (98%) | 53 (79%) | 1589 (98%) | |
| Yes | 42 (2%) | 14 (21%) | 28 (2%) | |
| Reported Drug Use | <0.001 | |||
| No | 1349 (80%) | 32 (48%) | 1317 (81%) | |
| Yes | 335 (20%) | 35 (52%) | 300 (19%) | |
| Reported Injection Drug Use | <0.001 | |||
| No | 1655 (98%) | 62 (93%) | 1593 (99%) | |
| Yes | 29 (2%) | 5 (7%) | 24 (1%) | |
| Had Prenatal Care (PNC) | 0.02 | |||
| No or Unknown | 395 (23%) | 24 (36%) | 371 (23%) | |
| Yes | 1289 (77%) | 43 (64%) | 1246 (77%) | |
| Gestational Age at First PNC Visit (wks): Median (Q1, Q3) | 11.9 (8.6, 18.0) | 17.3 (9.6, 23.1) | 11.9 (8.6, 17.7) | 0.07 |
| Urbanicity b | <0.001 | |||
| Large Urban | 202 (12%) | 20 (30%) | 182 (11%) | |
| Large Suburban | 656 (39%) | 30 (45%) | 626 (39%) | |
| Small/Medium Urban | 553 (33%) | 12 (18%) | 541 (34%) | |
| Rural/Non-Core | 265 (16%) | 5 (7%) | 260 (16%) | |
| Social Vulnerability Index: Household Type c | 0.08 | |||
| Low-to-Medium | 722 (43%) | 22 (33%) | 700 (44%) | |
| High-to-Very-High | 952 (57%) | 45 (67%) | 907 (56%) | |
| Percent of Families Living Under FPLd: Median (Q1, Q3) | 6.8 (3.8, 13.1) | 8.9 (4.5, 13.6) | 6.8 (3.8, 13.1) | 0.34 |
| Percent of Families Living Under FPLd Categories | 0.27 | |||
| 10% or less | 1074 (65%) | 39 (58%) | 1035 (65%) | |
| Over 10% | 589 (35%) | 28 (42%) | 561 (35%) |
ENPNS = early non-primary, non-secondary syphilis;
Urbanicity, categorized using the CDC’s 2023 National Center for Health Statistics urban-rural classification scheme;
CDC Social Vulnerability Index (SVI), Theme 4 – Housing Type and Transportation; captures neighborhood vulnerability based on housing characteristics (multi-unit structures, mobile homes, group quarters, crowding) and transportation access (no vehicle), using data from the 5-year American Community Survey at the census-tract level;
FPL = federal poverty level; census-tract–level metric derived from U.S. Census Bureau data.
Six individuals were missing data on race/ethnicity.
Pre-Birth MMHC Mention Prevalence and Correlates
Overall, 4% (n=67) had pre-birth MMHC mentions in STI surveillance records. Among those with mentions, 42% involved unspecified mental health concerns, 28% mood disorders, 4% psychotic disorders, and 22% both mood and psychotic features. One-quarter also had suicidal ideation or self-harm documented.
MMHC documentation varied by maternal characteristics (Table S2) and was higher among women reporting drug use (10%), HIV diagnosis (19%), and a history of domestic or sexual violence (33%). Women with pre-birth MMHC mentions were also more likely to have no or unknown prenatal care than those without (36% vs. 23%) and initiated prenatal care later (median 17.3 vs. 11.9 weeks; Table 1).
In adjusted analysis (Table S2), odds of documented MMHC in STI surveillance data were higher among women with a history of violence experience (adjusted odds ratio [aOR] 8.2 [95% CI 3.7–18.4]), HIV infection (aOR 5.4 [95% CI 1.7–16.8]), reported drug use (aOR 4.0 [95% CI 2.3–6.9]), or residence in large urban areas (aOR 3.9 [95% CI 1.3–11.5]).
Association of Pre-Birth MMHC Mention with CS Outcomes
Among 1,684 SyAPs, 416 (25%) experienced a CS outcome, including 24 syphilitic stillbirths. CS prevalence was higher among SyAPs with pre-birth MMHC mentions than those without (36% vs. 24%; Table 2). After adjustment for maternal age, race/ethnicity, HIV status, census tract–level poverty, violence experience, and housing and transportation vulnerability, pre-birth MMHC mention was associated with higher CS prevalence (aPR 1.5, [95% CI: 1.1–2.1]), indicating that CS prevalence was 50% higher among SyAPs with pre-birth MMHC documentation compared with those without. Stratified analyses showed modest variation in the association across race/ethnicity, urbanicity, and area-level socioeconomic status; however, likelihood ratio tests indicated no statistically significant heterogeneity (Table S3).
Table 2.
Associations between Pre-Birth Maternal Mental Health Concerns and Congenital Syphilis, Georgia (2018 – 2023)
| N | Had a CS Outcome in Index Pregnancy | Unadjusted Prevalence Ratio‡ | Adjusted Prevalence Ratio‡ | |||
|---|---|---|---|---|---|---|
| n (%) | PR (95% Cl) | p value | aPR (95% Cl) | p value | ||
| Had a maternal mental health concern mention in syphilis case investigation notes in year before delivery | ||||||
| Yes | 67 | 24 (36%) | 1.48 (1.06, 2.06) | 0.02 | 1.50 (1.05, 2.14) | 0.03 |
| No | 1617 | 392 (24%) | Ref | Ref | ||
Modified Poisson regression model (multivariable model was adjusted for maternal age (categories), race/ethnicity, HIV status, violence (domestic violence/sexual assault) experience, proportion of families living below the federal poverty level [census-tract–level metric derived from U.S. Census Bureau data, dichotomized to 10% or less and over 10% categories], and CDC Social Vulnerability Index (SVI), Theme 4 [Housing Type and Transportation; captures neighborhood vulnerability based on housing characteristics (multi-unit structures, mobile homes, group quarters, crowding) and transportation access (no vehicle), using data from the 5-year American Community Survey at the census-tract level])
Effect Modification by Household Composition
In the analytic cohort, 39% lived with a partner or family members, 19% lived alone or with non-family members, and 41% had unknown living situations. Stratified analyses suggested a less pronounced association between pre-birth MMHC mentions and CS outcomes among women living with partners or family (aPR 1.18 [95% CI 0.57–2.47]) compared with those living alone or with non-family members (aPR 1.42 [95% CI 0.70–2.90]); however, these differences were not statistically significant (p > 0.05).
Internal Validation Substudy & Quantitative Adjustment for Misclassification Bias
A total of 167 participants were selected for the internal validation substudy, including all 67 women with pre-birth MMHC mentions in surveillance data and a random sample of 100 women without mentions. Electronic medical records were available for 83 (50%) of these mothers. The PPV of surveillance-identified pre-birth MMHC was 46% among CS cases and 22% among non-cases (Table S4). In both groups, a substantial proportion of women classified as not having pre-birth MMHC in surveillance data had documentation of pre-birth MMHC in medical records (53% of cases and 35% of non-cases), corresponding to NPVs of 47% and 65%, respectively.
Bias-adjusted analyses accounting for likely MMHC misclassification suggested a stronger association between pre-birth MMHC mentions and CS events than estimated in primary analysis, although substantial uncertainty remained (aPR 2.1 [95% simulation interval 0.8–5.0]).
DISCUSSION
This study examined pre-birth MMHC mentions among women with syphilis-affected pregnancies, their association with congenital syphilis, and whether this relationship was modified by likely sources of support within maternal immediate social environment. Pre-birth MMHC mentions were uncommon in STI surveillance records, documented in only 4% of syphilis-affected pregnancies during the study period, but were associated with higher prevalence of subsequent CS outcomes. Although the magnitude of association did not differ statistically by household composition, it was less pronounced among women living with partners or family members compared with those living alone or with non-family members. These findings suggest that pre-birth MMHC documented during syphilis case investigations may represent a useful marker of vulnerability and a potential target for interventions to reduce missed opportunities for CS prevention.
Pre-birth MMHC prevalence in this cohort was low, likely reflecting limitations in surveillance-based ascertainment rather than the true burden of MMHCs among pregnant women with syphilis. Prior research suggests that prenatal mental health conditions are more common than observed here, with studies reporting that 8–15% of pregnant women experience depressive symptoms and up to 20% experience anxiety.37–40 Our internal validation findings further support the interpretation of MMHC under-ascertainment, as many women classified as not having pre-birth MMHC in surveillance data had MMHC documentation in medical records. Several factors may contribute to this discrepancy. Mental health is not routinely assessed during most public health disease investigation workflows, and elicitation during STI case investigations often depends on the training, awareness, and comfort of interview staff. Observed differences in MMHC mentions across subgroups, such as higher reporting among women with HIV, may therefore reflect variation in elicitation intensity related to co-existing conditions rather than true differences in prevalence. Stigma surrounding mental health may also contribute by limiting disclosure, while underdiagnosis and low utilization of mental health services can result in symptoms going unrecognized by women themselves, reducing reporting. Consequently, MMHC captured in STI surveillance likely represents the subset of patient disclosed or clinically apparent conditions and may be most appropriately interpreted as a marker of vulnerability rather than a comprehensive measure of maternal mental health burden among women with syphilis. The limited capture of MMHC observed in this cohort highlights the potential value of attention to mental health indicators during syphilis case investigations especially among women. While comprehensive screening may not be feasible, increased attention to these indicators could help identify individuals at elevated risk for missed CS prevention opportunities and support timely referral, follow-up, and care coordination.41
The association between pre-birth MMHC mentions and subsequent CS outcomes highlights maternal mental health as a potentially important upstream determinant of CS risk among pregnant women with syphilis. This association remained robust after adjusting for maternal age, race/ethnicity, HIV status, violence experience, socioeconomic status, and housing and transportation vulnerability, and persisted, albeit with greater uncertainty, after accounting for likely misclassification of pre-birth MMHC inherent in surveillance data. Pre-birth MMHC prevalence was also correlated with patterns of prenatal care engagement that may contribute to CS risk in the study population: women with documented pre-birth MMHC were more likely to have no or unknown prenatal care, and among those with known gestational age at prenatal care initiation, entry into care occurred later than for women without pre-birth MMHC. These patterns align with prior evidence that mental health concerns can disrupt care-seeking and continuity, creating delays in healthcare engagement and barriers to timely diagnosis and treatment.13–15,23,28,41 Although surveillance-based documentation likely underestimates the true burden of maternal mental health conditions among women with syphilis, the subset captured by current STI case investigations appears to identify those at elevated risk of CS outcomes, suggesting that pre-birth MMHC mentions in surveillance data may serve as a leverage point for intervention. For pregnant women with syphilis who have a documented MMHC, linkage to mental health services and enhanced follow-up to ensure timely prenatal care, adherence to syphilis screening and treatment, and appropriate third-trimester testing could help reduce missed opportunities for CS prevention.
Stable social support within a woman’s immediate environment may buffer some of the adverse effects of MMHC. Although effect modification was not statistically significant in this study, the association between pre-birth MMHC and CS outcomes was attenuated among women living with family or partners than among those living alone or with less stable sources of support. Evidence from other populations confirms that close, reliable interpersonal ties can reduce stress, enhance coping, and promote healthcare engagement during pregnancy.42,43 Among SyAPs, such support may help women overcome barriers to timely prenatal care by providing instrumental assistance, (e.g., appointment reminders or transportation), and encouraging consistent treatment engagement, which may in turn help reduce CS risk, including among those experiencing mental health challenges. These findings also highlight intervention opportunities beyond clinical care. In addition to strengthening linkage to mental health, substance use, and HIV services, public health programs may benefit from facilitating access to supportive resources for women lacking consistent support. Community-based programs providing instrumental assistance (e.g. transportation to appointments, care reminders, or childcare) may be particularly valuable for women who lack stable or consistent support within their immediate environment. For those living with family or partners, strategies that encourage their involvement, where acceptable to the mother, may also support care engagement and reduce missed opportunities for CS prevention.
This study has several limitations. MMHC were identified from unstructured surveillance text, which may be inconsistently or incompletely recorded due to differences in documentation practices across jurisdictions and staff. Although statistical models used adjusted for key demographic and structural factors, residual confounding may persist from unmeasured characteristics, such as underlying medical conditions, prior adverse pregnancy outcomes or environmental stressors that influence both maternal mental health and CS risk. Social support was proxied by household composition at the time of the syphilis case investigation, which does not capture its multidimensional nature and may misclassify actual support. “Living with” does not necessarily reflect perceived or received support; definitions of “family” vary; and some living situations may be sources of stress, (e.g., abusive or unstable environments). Additionally, household composition at interview may not reflect support available throughout pregnancy. Pre-birth MMHC mentions were uncommon in surveillance data, likely reflecting under-ascertainment rather than true prevalence. Although bias adjustment for misclassification was applied in main analysis, stratified analyses were not similarly adjusted and may be more susceptible to attenuation and reduced precision; findings should be interpreted with caution. The cross-sectional nature of the data limits causal inference regarding temporal relationships among maternal mental health, healthcare engagement, and CS outcomes, although restricting MMHC to mentions documented before delivery strengthens confidence that exposure preceded outcome. Finally, because the study is limited to women with SyAPs in Georgia, findings may not generalize to regions with different demographics, healthcare systems, or syphilis epidemiology.
This study highlights maternal mental health as an actionable indicator of potential CS risk within an STI surveillance context. Even incompletely captured, pre-birth MMHC mentions correlated with delayed or absent prenatal care and were associated with increased CS prevalence, suggesting that maternal mental health may operate upstream of the missed opportunities that lead to preventable congenital infections. From a public health perspective, leveraging STI case investigations to identify MMHC during pregnancy, coupled with mental health-informed workflows, provides an opportunity to initiate timely referrals, enhance care coordination, and link women to protective community-based support. Recognizing and addressing maternal mental health in this context offers a concrete pathway to strengthen efforts toward the elimination of CS in the US.
Supplementary Material
ACKNOWLEDGEMENTS
We gratefully acknowledge the women whose experiences informed this analysis and look forward to a Georgia free of congenital syphilis. We also thank the Communicable Disease Specialists across Georgia, whose frontline efforts ensure that syphilis and other sexually transmitted infections are thoroughly investigated and addressed. Their work is essential in shaping effective public health responses.
Footnotes
DECLARATIONS
Conflicts of interest: The authors have no relevant financial or non-financial interests to disclose.
DISCLAIMER
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
ETHICS APPROVAL
Research Involving Human Participants: The study adhered to federal regulations governing human subject protection in accordance with the Helsinki declaration and received approval from Georgia Department of Public Health’s Institutional Review Board (Project 250402).
Informed Consent: The requirement for informed consent was waived by the Georgia Department of Public Health’s Institutional Review Board due to the study involving minimal risk to participants whose data were used.
Data Availability:
The data underlying this study cannot be publicly shared due to ethical and legal restrictions concerning patient confidentiality and privacy.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data underlying this study cannot be publicly shared due to ethical and legal restrictions concerning patient confidentiality and privacy.