Genital Chlamydia Trachomatis Infection: Prevalence, Risk Factors and Adverse Pregnancy and Birth Outcomes in Children and Women in sub-Saharan Africa

3.1. Pre-term Birth

Pregnant women with genital CT are often asymptomatic, however, where there are systems, there is abnormal vaginal discharge, bleeding after sex, or itching and burning with urination. If left untreated, genital CT infection may lead to pre-term birth:15 the delivery of a live birth before 37 weeks of gestation.16 Studies suggest that chlamydial infections increase the risk for pre-term delivery and/or low birth weight. As such, pre-term births have been identified as one of the main causes of perinatal morbidity and mortality, accounting for about 27% of the nearly four million reported annual neonatal deaths.17 They also serve as a risk factor for chronic lung disease, infections, and neurologic disabilities including intracranial hemorrhage, cerebral white matter damage, and cerebral palsy in children.17 According to Vogel et al., genital CT is a leading contributor to neonatal and child mortality in sub-Saharan Africa.18 In their study on genital CT in South Africa and Cameroon, van Rensburg and Odendaal noted that pregnant women with genital CT infection were three times more likely to experience pre-term labor (OR 2.8, 95% CI 1.1–6.97) than their uninfected counterparts.19

3.2. Low-birth Weight

Genital CT places unborn children at risk for low birth weight (babies less than 5 pounds at birth). Low birth weight is a major risk factor for neonate and infant morbidity and mortality, especially in sub-Saharan Africa. While it is unclear how chlamydia infection results in low birth weight, it is known that maternal infection contributes close to 40% of low birth cases.20 A secondary analysis of 1,373 pregnant women in South Africa showed high rates of low birth weight (43%) and pre-term birth (29%) among women with high genital CT.17 Complications associated with low birth weight may cause babies to have difficulty eating, gaining weight, or fighting off infections.20

3.3. Miscarriage

According to some researchers, genital CT is a potential trigger for miscarriage, accounting for about 15% of early miscarriages (<12 weeks of gestation) and up to 66% of late miscarriages (>12 weeks of gestation).21 In a study conducted to analyze serum, cervicovaginal swab specimens and placenta samples of 386 women, researchers found an increased risk of miscarriage among women who had been exposed to genital CT compared to women who had not been exposed to the infection.22 Researchers noted that during pregnancy, genital CT may infect the fetus, triggering the release of cytokine and thus resulting in miscarriage, premature rupture of membranes, or possibly a maternal inflammatory response.23 In their study, Auult et al. hypothesized that maternal inflammatory responses to chlamydial heat shock protein (CHSP-60) could cause tubal damage leading to tubal infertility and ectopic pregnancy.24

3.4. Conjunctivitis

Earlier studies have shown that genital CT can be vertically transmitted from mothers to infants during delivery.25,26 Those same studies also predicted that approximately 50–70% of infants born to untreated mothers would become infected with genital CT and that 30–50% of those infections would cause conjunctivitis and 10–20% would cause pneumonia.25,26 Indeed, studies in sub-Saharan Africa have corroborated these predictions as similarly high rates of genital CT vertical transmission have been recorded among infants.27 In their research in Cameroon, Buisman et al. found that 19.4% of the 449 infants they studied had conjunctivitis that was due to genital CT,28 and upon studying 277 children in Kenya, Datta et al. reported that about 9% of the infants evaluated for conjunctivitis were also infected with genital CT.29

Also known as “pink eye,” conjunctivitis is caused by a viral or bacterial infection of the conjunctiva. Babies often become infected with conjunctivitis during vaginal delivery. Symptoms of the infection include swelling of the eyelids, redness of the eye, and the discharge of pus,30 which usually develops 5-14 days after birth.31 Consequences of untreated conjunctivitis in babies are vision loss (in rare cases), neovascularization of the cornea, and scarring.

3.5. Pneumonia

Often underdiagnosed in infants, chlamydial pneumonia tends to be a subacute, afebrile infection that typically occurs in infants between one and three months of age. In younger premature infants, chlamydial pneumonia can be severe, causing apnea and possible hospitalization. Although mortality from chlamydial pneumonia is rare in children, if left untreated, the condition can persist for several weeks and lead to poor feeding, diminished weight gain, asthma, and chronic lung disease at an advanced age. The results of studies conducted on infants in sub-Saharan Africa suggested that genital CT may be a frequent pathogen in lower respiratory tract infections including pneumonia among infants.26,32 In a study that evaluated genital CT in infants in Ethiopia, Kenya, and South Africa, researchers noted that genital CT was a frequent isolate (6–51%) from infants with lower respiratory tract infections including pneumonia.33-35 Per the Ethiopian study, genital CT was found to be the second most common infectious condition (15.8%) among infants less than 3 months presenting with pneumonia.33

4.1. Low Educational Levels

Researchers attending an out-patient clinic for women of reproductive age at Ahmadu Bello University Teaching Hospital in Northern Nigeria found that low educational level was associated with a greater likelihood of acquiring genital CT.36 In their study on the prevalence of genital CT infection among patients attending infertility and sexually transmitted diseases clinic in Kano, Nigeria, Nwankwo and Sadiq noted that 95.2% of patients including women, were completely ignorant about the infection and its risk factors.37 They noted that women who were educated were more aware of how to prevent genital CT transmission than their illiterate counterparts.

4.2. Commercial Sex

Across sub-Saharan Africa, the demand for transactional sex outside marriage is met by commercial sex workers. In many cities, particularly those in East and Southern Africa, commercial sex workers usually have multiple clients whom they service on a weekly or daily basis. Sexual activities with multiple and repeat clients and higher prices for sex without the utilization of condoms, put commercial sex workers at higher risk for genital CT.38,39 Onoyo et al. documented a significant relationship (OR = 2.8, P < 0.002) between women with multiple sexual partners and genital CT in South Africa.40 In their study in Tanzania, Uthman and Kongnyuy observed that transactional sex enabled commercial sex workers to meet their financial and subsistence needs (as food, rent or school fees) or to have access to lifestyle items such as fashionable clothes, jewelry, or cellphones.41

4.3. Lack of Condom Use

While condoms are an effective means of reducing the transmission of genital CT, gender power relations and cultural norms in many sub-Saharan African countries make it difficult for women to suggest or negotiate condom use with their partners. Such requests are often met with suspicions of infidelity and even the threat of divorce or violence. Orubuloye et al. concluded that social, cultural, political, and gender-power dynamics within Nigeria constrain women’s ability to introduce condoms into their relationships.42 It is only in situations where women have more economic resources than their partners that they can negotiate condom use.42 The lack of communication among partners concerning condom use, moral values, and religious factors also put women at risk for genital CT.43

5.1. Cultural Practices

Cultural practices such as widow inheritance, sexual cleansing, and polygamy make genital CT prevention in sub-Saharan Africa a challenge. While widow inheritance, the marriage of a widow to her deceased husband’s brother, maintains the social and economic welfare of widows and children, it creates extended sexual networks that do not protect the reproductive health of women. Where sexual cleansing rituals for widows are practiced, women are often at high risk for genital CT as cleansers engage in unprotected sex and may perform many rituals throughout their lifetime.44 Additionally, culturally sanctioned gender power relations place women in subordinate positions to men, making it difficult for women to refuse unsafe sex or to insist on condom use.

To address these cultural practices, governments and societies in sub-Saharan countries need to promote monogamy (even beyond spousal death), gender equity, uphold the reproductive health of women, implement strategies to reinforce women’s right to self-determination, and severely punish perpetrators of acts that violate the reproductive rights of women.

5.2. Illiteracy

Sub-Saharan Africa has the highest illiteracy rate in the world and approximately 70% of the illiterate population are women.45 Lack of education often results in a lack of skills and access to job opportunities, money, and assets. These socio-economic conditions push some women to engage in risky sexual behaviors.46 In a study conducted to investigate genital CT among asymptomatic female commercial sex workers in Ghana, researchers found that 41% of the women had no formal education.8 They also found that the women were reluctant to seek medical attention for genital CT due to ignorance and the disrespectful treatment they receive from healthcare providers.8

Giving women and girls access to education should be at the core of national developmental efforts in sub-Saharan Africa. Through education, women and girls will become informed and empowered to make informed decisions about their reproductive health. This is crucial to the reduction of genital CT acquisition and transmission as literacy has been found to be linked to increased adoption of protective health behaviors.47

5.3. Lack of Screening

Most sub-Saharan African countries use the syndromic approach endorsed by the World Health Organization to test for genital CT.4 While a good approach, genital CT is often asymptomatic in women. Thus, the total reliance on this approach by health care providers hinders their ability to identify the infection early and to begin early treatment before irreparable damage is done. Additionally, the syndromic approach has the tendency to produce false positive and negative results,4 resulting in some women receiving the treatment they do not need and preventing those who need treatment from receiving it, thereby facilitating potential transmission.4

To tackle this challenge, health systems in sub-Saharan Africa need to combine the syndromic approach with genital CT screening for pregnant women or women looking to become pregnant, so they may be treated early if they test positive for the infection. This will help to reduce vertical and horizontal transmission.