JAMA Health Forum. 2026 Mar 6;7(3):e260123. doi: 10.1001/jamahealthforum.2026.0123.
ABSTRACT
IMPORTANCE: Rates of congenital syphilis in the US have surged over the past decade, despite most states having long-standing mandates requiring clinicians to offer syphilis screening early in pregnancy. Gaps in screening coverage remain, and first-trimester screening alone may miss cases. Several professional bodies now recommend repeat screening in the third trimester and at delivery. Evidence on the impact of expanded prenatal syphilis screening mandates on case detection is limited.
OBJECTIVE: To evaluate the effectiveness of expanding prenatal syphilis screening mandates on syphilis case detection during pregnancy.
DESIGN, SETTING, AND PARTICIPANTS: Birth certificate data from 33 US states between 2012 and 2022 were analyzed using a staggered difference-in-differences design. Maternal syphilis case detection in 4 states that enacted mandates for third-trimester and delivery screening (Arizona, Georgia, Louisiana, and Michigan) were compared with 29 control states without such mandates during this period. The new mandates required all pregnant people be offered third-trimester screening. Three of the states further required that individuals at high risk of syphilis infection be offered screening again at delivery, and 1 state required universal delivery screening. To ascertain whether expanded mandates were associated with changes in screening coverage, inpatient discharge records from 1 mandate expansion state (Georgia) were analyzed. Data were analyzed from December 2024 to September 2025.
EXPOSURES: Passage of a universal syphilis screening mandate in the third trimester and a high-risk or universal mandate at delivery between 2012 and 2022.
MAIN OUTCOMES AND MEASURES: Maternal syphilis case detection (cases per 100 000 live births) and the share of deliveries receiving syphilis screening.
RESULTS: The study sample included 16.3 million live births and 20 961 reported syphilis cases between 2012 and 2022 in 4 mandate expansion states and 29 control states. Expanded screening mandates were associated with a 26% (95% CI, 3-53) increase in maternal syphilis case detection in the first quarter after enactment. The increase in case detection attenuated thereafter and was no longer significant within 1 year (11%; 95% CI, -17 to 48; P = .48).
CONCLUSIONS AND RELEVANCE: In this study, expanded prenatal syphilis screening mandates may improve syphilis case detection in the near-term but are unlikely to have sustained impact without complementary efforts, such as those that facilitate clinician adherence and ensure patient access to and completion of treatment.
PMID:41860538 | DOI:10.1001/jamahealthforum.2026.0123
