Maternal and Child Health Journal

, Volume 15, Issue 7, pp 1020–1028

Evaluation of Syracuse Healthy Start’s Program for Abnormal Flora Management to Reduce Preterm Birth Among Pregnant Women

  • Emilia H. Koumans
  • Sandra D. Lane
  • Richard Aubry
  • Kathleen DeMott
  • Noah Webster
  • Brooke A. Levandowski
  • Stuart Berman
  • Lauri E. Markowitz


Randomized trials of bacterial vaginosis (BV) treatment among pregnant women to reduce preterm birth have had mixed results. Among non-pregnant women, BV recurs frequently after treatment. Randomized trials of early BV treatment for pregnant women in which recurrence was retreated have shown promise in reducing preterm birth. Syracuse’s Healthy Start (SHS) program began in 1997; in 1998 prenatal care providers for pregnant women living in high infant mortality zip codes were encouraged to screen for abnormal vaginal flora at the first prenatal visit. Vaginal swabs were sent to a referral hospital laboratory for Gram staining and interpretation. SHS encouraged providers to treat and rescreen women with bacterial vaginosis or abnormal flora (BV). We abstracted prenatal and hospital charts of live births between January 2000 and March 2002 for maternal conditions and treatments. We merged abstracted data with local electronic data. We evaluated the effect of BV screening before 22 weeks gestation, treatment, and rescreening using a retrospective cohort study design. Among 838 women first screened before 22 weeks, 346 (41%) had normal flora and 492 (59%) women had BV at a mean of 13 weeks gestation; 202 (24%) did not have treatment documented and 290 (35%) received treatment at a mean of 15 weeks gestation; 267 (92%) of those treated were re-screened. Among pregnant women with early BV, 42 (21%) untreated women and 28 (10%) treated women delivered preterm (Odds Ratio [OR] 0.4, 95% confidence interval [CI] 0.2–0.7)). After adjustment for age, race, prior preterm birth and other possible confounders, treatment remained associated with a reduced risk of preterm birth compared to no treatment (aOR = 0.5, 95% CI 0.3–0.9); the aOR for women with normal flora was not significantly different. Conclusion: Screening, treatment, and rescreening for BV/abnormal flora between the first prenatal visit and 22 weeks gestation showed promise in reducing preterm births and deserves further study.


Premature birth Vaginosis, bacterial Prenatal care 


  1. 1.
    Schwebke, J. R., Richey, C. M., & Weiss, H. L. (1999). Correlation of behaviors with microbiological changes in vaginal flora. The Journal of Infectious Diseases, 180, 1632–1636.PubMedCrossRefGoogle Scholar
  2. 2.
    Koumans, E. H., Sternberg, M., Bruce, C., McQuillan, G., Kendrick, J., Sutton, M., et al. (2007). The prevalence of bacterial vaginosis in the United States, 2001–2004; Associations with symptoms, sexual behaviors, and reproductive health. Sexually Transmitted Diseases, 34(11), 864–869.PubMedCrossRefGoogle Scholar
  3. 3.
    Brotman, R. M., Ravel, J., Cone, R. A., Zenilman, J. M. Vaginal microbiota frequently undergo rapid fluctuations. Presented at the 2009 International Society for STD Research, abstract P4.137, p. 277.Google Scholar
  4. 4.
    Riggs, M., Klebanoff, M., Nansel, T., Zhang, J., Schwebke, J., & Andrews, W. (2007). Longitudinal association between hormonal contraceptives and bacterial vaginosis in women of reproductive age. Sexually Transmitted Diseases, 34, 954–959.PubMedGoogle Scholar
  5. 5.
    Sobel, J. D., Ferris, D., Schwebke, J., Nyirjesy, P., Wiesenfeld, H. C., Peipert, J., et al. (2006). Suppressive antibacterial therapy with 0.75% metronidazole vaginal gel to prevent recurrent bacterial vaginosis. American Journal of Obstetrics and Gynecology, 194(5), 1283–1289.PubMedCrossRefGoogle Scholar
  6. 6.
    Klebanoff, M. A., Hauth, J. C., MacPherson, C. A., Carey, J. C., Heine, R. P., Wapner, R. J., et al. (2004). Time course of the regression of asymptomatic bacterial vaginosis in pregnancy with and without treatment. American Journal of Obstetrics and Gynecology, 190(2), 363–370.PubMedCrossRefGoogle Scholar
  7. 7.
    Leitich, H., & Kiss, H. (2007). Asymptomatic bacterial vaginosis and intermediate flora as risk factors for adverse pregnancy outcome. Best Practice and Research in Clinical Obstetrics and Gynaecology, 21(3), 375–390.CrossRefGoogle Scholar
  8. 8.
    Gotsch, F., Romero, R., Kusanovic, J. P., Mazaki-Tovi, S., Pineles, B. L., Erez, O., et al. (2007). The fetal inflammatory response syndrome. Clinical Obstetrics and Gynecology, 50(3), 652–683.PubMedCrossRefGoogle Scholar
  9. 9.
    Cunningham, F. G., Gant, N. F., Leveno, K. J., Gilstrap, L., Hauth, J. C., & Wenstrom, K. D. (2001). Williams obstetrics (21st ed., p. 79). New York: MacGraw-Hill Medical Publishing Division.Google Scholar
  10. 10.
    Nygren, P., Fu, R., Freeman, M., Bougatsos, C., Klebanoff, M., Guise, J. M., et al. (2008). Evidence on the benefits and harms of screening and treating pregnant women who are asymptomatic for bacterial vaginosis: An update review for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 148(3), 220–233.PubMedGoogle Scholar
  11. 11.
    Ugwumadu, A., Manyonda, I., Reid, F., & Hay, P. (2003). Effect of early oral clindamycin on late miscarriage and preterm delivery in asymptomatic women with abnormal vaginal flora and bacterial vaginosis: A randomized controlled trial. Lancet, 361, 983–988.PubMedCrossRefGoogle Scholar
  12. 12.
    Lamont, R. F., Duncan, S. L. B., Mandal, D., & Bassett, P. (2003). Intravaginal clindamycin to reduce preterm birth in women with abnormal genital tract flora. Obstetrica et Gynaecologica, 101, 516–522.Google Scholar
  13. 13.
    Larsson, P. G., Fahraeus, L., Carlsson, B., Jakobsson, T., & Forsum, U. (2006). Late miscarriage and preterm birth after treatment with clindamycin: A randomised consent design study according to Zelen. Premature study group of the Southeast Health Care Region of Sweden. BJOG: An International Journal of Obstetrics and Gynaecology, 113(6), 629–637.CrossRefGoogle Scholar
  14. 14.
    Hauth, J. C., Goldenberg, R. L., Andrews, W. W., DuBard, M. B., & Copper, R. L. (1995). Reduced incidence of preterm delivery with metronidazole and erythromycin in women with bacterial vaginosis. New England Journal of Medicine, 333(26), 1732–1736.PubMedCrossRefGoogle Scholar
  15. 15.
    Spiegel, C. A., Amsel, R., & Holmes, K. K. (1983). Diagnosis of bacterial vaginosis by direct gram stain of vaginal fluid. Journal of Clinical Microbiology, 18(1), 170–177.PubMedGoogle Scholar
  16. 16.
    Centers for Disease Control and Prevention. (2006). Guidelines for treatment of sexually transmitted diseases. MMWR. Morbidity and Mortality Weekly Report, 47(RR-11), 50–52.Google Scholar
  17. 17.
    Goldenberg, R. L., & Rouse, D. J. (1998). Prevention of premature birth. New England Journal of Medicine, 339(5), 313–320.PubMedCrossRefGoogle Scholar
  18. 18.
    Lee, S. E., Romreo, R., Jung, H., Park, C. W., Park, J. S., & Yoon, B. H. (2007). The intensity of the fetal inflammatory response in intraamniotic inflammation with and without microbial invasion of the amniotic cavity. American Journal of Obstetrics and Gynecology, 197, 294.e1–294.e6.CrossRefGoogle Scholar
  19. 19.
    Siegel, I., & Gleicher, N. (1981). Development of the fetal immune system. Progress in Clinical and Biological Research, 70, 31–40.PubMedGoogle Scholar
  20. 20.
    Hay, P. E., Lamont, R. F., Taylor-Robinson, D., Morgan, D. J., Ison, C., & Pearson, J. (1994). Abnormal bacterial colonisation of the genital tract and subsequent preterm delivery and late miscarriage. British Medical Journal, 308(6924), 295–298.PubMedGoogle Scholar
  21. 21.
    Gratacos, E., Figueras, F., Barranco, M., Vila, J., Cararach, V., Alonso, P. L., et al. (1998). Spontaneous recovery of bacterial vaginosis during pregnancy is not associated with an improved perinatal outcome. Acta Obstetricia et Gynecologica Scandinavica, 77(1), 37–40.PubMedCrossRefGoogle Scholar
  22. 22.
    The Coronary Drug Project Research Group. (1980). Influence of adherence and response of cholesterol on mortality in the coronary drug project. The New England Journal of Medicine, 303, 1038–1041.CrossRefGoogle Scholar

Copyright information

© US Government 2010

Authors and Affiliations

  • Emilia H. Koumans
    • 1
  • Sandra D. Lane
    • 2
  • Richard Aubry
    • 3
  • Kathleen DeMott
    • 4
  • Noah Webster
    • 5
  • Brooke A. Levandowski
    • 6
  • Stuart Berman
    • 1
  • Lauri E. Markowitz
    • 1
  1. 1.Division of STD PreventionCenters for Disease Control and PreventionAtlantaUSA
  2. 2.Departments of Health and WellnessSyracuse UniversitySyracuseUSA
  3. 3.Center for Maternal and Child Health and Department of Obstetrics and GynecologySUNY Upstate Medical UniversitySyracuseUSA
  4. 4.The Royal College of PhysiciansLondonUK
  5. 5.Syracuse Healthy Start/Case Western UniversityClevelandUSA
  6. 6.Syracuse Healthy Start/IpasChapel HillUSA

Personalised recommendations