“Syphilis is a normal thing that children are born with… ”: Understanding Barriers and Facilitators to Maternal and Congenital Syphilis Care in Kampala, Uganda
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Introduction
Congenital syphilis (CS) remains a major cause of preventable stillbirths and neonatal deaths globally. This qualitative study explored perceptions and experiences of mothers, partners, providers, and policymakers regarding the barriers and facilitators to implementing antenatal and newborn syphilis testing and treatment in Kampala, Uganda.
Methods
We conducted 15 in-depth interviews, four focus group discussions, and 16 key informant interviews between March and May 2022 with pregnant and postnatal women, male partners, health workers, traditional birth attendants, and Ministry of Health policymakers. Data were analyzed using the Consolidated Framework for Implementation Research (CFIR) in NVivo 12 and reported following the COREQ checklist.
Results
Participants valued syphilis screening and treatment to protect infant health, particularly when they understood the consequences of untreated infection. Facilitators included respectful counselling, phone-based follow-up, and integration of testing into routine antenatal care. Key barriers included fear of painful injections, stigma and disclosure risk, low male-partner involvement, fragmented information systems, limited infant diagnostics, and medication stockouts. Partner notification was hindered by fears of infidelity accusations and relationship conflict. Notably, caregivers frequently refused treatment for asymptomatic infants due to misconceptions that only visibly ill children required care. Facility opportunities to strengthen the syphilis care cascade were identified such patient tracing systems and strengthened supply chains.
Conclusions
Addressing CS requires community education, non-parenteral treatment alternatives, and affordable confirmatory neonatal testing. Stronger supply chains, integrated maternal-infant-partner care pathways, better-equipped health workers, male-engagement strategies, and consistent follow-up are needed to accelerate elimination of mother-to-child syphilis transmission in Uganda and similar settings.
What is already known on this topic
Congenital syphilis (CS) remains a major cause of preventable stillbirths and neonatal deaths, but the views of people delivering and receiving syphilis care in Uganda are poorly understood.
What this study adds
Participants valued CS screening and treatment to protect infants, and facilitators included respectful counselling, phone follow-up and routine antenatal integration. Barriers included fear of injections, stigma, low male-partner involvement, weak information systems, stockouts of supplies, lack of CS confirmatory tests and caregivers refusing prolonged intravenous treatment for infants without symptoms.
How this study might affect research, practice or policy
Programmes need community education, male engagement, patient tracing, stronger supply chains and integrated maternal-infant-partner care. Research should prioritise non-injectable, shorter duration infant treatments and affordable neonatal confirmatory testing.
Summary
This qualitative study in Kampala, Uganda explored barriers and facilitators to maternal and congenital syphilis care. Key barriers included fear of painful injections, stigma, low male-partner involvement, and treatment refusal for asymptomatic infants. Facilitators included respectful counselling, phone follow-up, and integrating syphilis testing into routine antenatal care.
