Impact of an education campaign on management in pregnancy of women infected with a blood-borne virus

Universal screening of pregnant women for HIV and hepatitis viruses B and C (HBV and HCV) has been recommended by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) since 2004.1 However, our survey of obstetricians in Australia in 2002–2003 found that their self-reported practice does not reflect these recommendations, with only 51% of respondents reporting they would always offer HIV testing, and 60% HCV testing.2

In addition, knowledge about management strategies to reduce perinatal transmission of blood-borne viruses and about transmission risk via breastfeeding appeared poor.2 Despite strong evidence that interventions such as elective caesarean section markedly reduce perinatal HIV transmission,3,4 only about a third of obstetricians reported always recommending this procedure and avoiding rupture of membranes in women with HIV infection. Further, about a third of obstetricians incorrectly advised that the risk of HBV transmission is increased with breastfeeding, and 47% gave the same advice about HCV.

Following this survey, we conducted an education campaign to improve obstetricians’ awareness. Here we report the results of a follow-up survey to assess the success of this campaign in:

• changing antenatal screening practice for blood-borne viruses;

• improving knowledge about interventions during labour that reduce rate of vertical transmission; and

• improving knowledge about the risk of transmission of infection via breastfeeding.

The follow-up survey was mailed to 743 of the 767 RANZCOG Fellows who had been sent Survey 1. The other 24 had died, retired, or were no longer practising for other reasons. A total of 502 questionnaires were returned (response rate, 68%); 38 were excluded from analysis as they were incomplete, or the respondent no longer practised obstetrics. Of the 502 respondents to Survey 2, 363 (72%) had also responded to Survey 1.

Following a simple educational intervention, we found a significant, albeit modest, increase in the proportion of obstetricians always offering antenatal HIV and HCV testing, and a similarly modest increase in knowledge about interventions to reduce vertical transmission of HIV and about risk of HBV and HCV transmission through breastfeeding.

A limitation of our study was the use of self-reported behaviour and knowledge as surrogate markers of clinical practice. Accuracy of clinician self-reported testing behaviour as a marker of actual testing practice and change post-intervention has been reported previously, although not in an antenatal setting.7 Our results could be strengthened by correlation of self-reported screening practice with data on antenatal testing for blood-borne viruses, and correlation of knowledge with actual clinical management. Studies are planned which will analyse de-identified data on laboratory antenatal HIV and HCV testing and national surveillance data on management of pregnancy in HIV-infected women in Australia.

A further limitation of the study was the use of mail-out questionnaires, which may have lower response rates and prevent any assessment of non-respondents. Another limitation was the inclusion of only registered obstetricians, as general practitioners and midwives may also be responsible for antenatal testing. Inclusion of these groups in future surveys may provide a more complete picture of antenatal screening practice in Australia.

Continuing education for health professionals is challenging, and reported efficacy varies between approaches and participants. Education and feedback on compliance with clinical guidelines has been reported as effective in modifying clinicians’ testing patterns,8 as has direct mail in increasing clinician knowledge.9 In contrast, formal continuing medical education and distribution of educational materials did not effectively change behaviour.10 When audit and feedback are effective, the change seems greater when baseline adherence to recommended practice is low.11 In our study, it is likely that the moderate effect seen after the education campaign relates to the initial low compliance with the RANZCOG guidelines for antenatal testing.

The purpose of antenatal screening for infectious diseases is to detect those which have the potential to affect the mother or fetus adversely, and for which there is an effective intervention. It is therefore of concern that a greater proportion of obstetricians always offer HCV compared with HIV screening, as there is minimal evidence to date that interventions reduce HCV transmission from mother to baby. In contrast, for HIV, there is extensive evidence that the transmission risk can be significantly reduced by interventions such as antiretroviral therapy for mother and neonate, delivery by caesarean section, and avoidance of breastfeeding,3,12-14

Our study was not designed to determine reasons for differences in antenatal screening rates. A possible factor contributing to the greater proportion of obstetricians always screening for HCV compared with HIV may be their greater familiarity with hepatitis screening, as 97% reported always including HBV testing in antenatal testing. In addition, the emphasis on counselling before HIV testing may be a barrier to offering this test in the antenatal setting. Other possible reasons that obstetricians do not perform universal HIV testing include lack of awareness of the RANZCOG recommendation, confusion given the contrary policy of government (which recommends offering HIV and HCV testing only to women identified with risk factors for exposure15,16), concerns over the cost of testing, or disagreement with the recommendation. To improve compliance with the RANZCOG recommendations, it is important to assess these potential barriers to universal screening.

If the reason for antenatal HCV screening is opportunistic — to detect women with asymptomatic chronic illness and a risk of long-term complications, which is modifiable by early treatment — then it is essential to audit how women with HCV infection are referred and managed postpartum, and the kind of information and medical support provided to them.

It is also of concern that our survey found an increase in the proportion of obstetricians who would change their clinical practice and always offer elective caesarean section to women with HCV infection. Reduced transmission of HCV with elective caesarean section has been reported in one small, observational study, whose authors warned of the need for a larger randomised trial before a change in clinical practice.17 Their findings contrast with a number of published observational studies that found no evidence of reduced transmission of HCV with elective caesarean section.18,19

Although antenatal HIV testing is not universal, our results suggest that it is offered more often since our education campaign. It would therefore be timely to evaluate the uptake and acceptability of HIV testing to women, adequacy of pre- and post-test counselling in the antenatal setting, and adequacy of resources to cope with the additional workload. With relatively small numbers of HIV-infected pregnant women in Australia, it is also important to develop mechanisms for appropriate referral and follow-up of those diagnosed with HIV infection during antenatal screening, along with guidelines for their clinical management.