'Syphilis is a normal thing that children are born with..' Understanding Barriers and Facilitators to Maternal and Congenital Syphilis Care in Kampala, Uganda

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.