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

Michelle L Giles, Suzanne M Garland, Sonia R Grover, Sharon M Lewin and Margaret E Hellard
Med J Aust 2006; 184 (8): 389-392. || doi: 10.5694/j.1326-5377.2006.tb00288.x
Published online: 17 April 2006

Abstract

Objective: To assess obstetricians’ antenatal screening practice for blood-borne viruses (HIV, hepatitis B and C viruses [HBV and HCV]) and knowledge about management during labour and risk of transmission via breastfeeding for infected women after an educational intervention.

Design: Cohort study, with surveys before and after an educational intervention.

Setting and participants: Survey 1 was mailed in 2002–2003 to all 767 Fellows registered with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), and Survey 2 was mailed in 2004 to the 743 of these Fellows who were still practising.

Intervention: Multifaceted intervention with mail-out of survey results and a summary of recommended management, publication of two review articles in the RANZCOG journal, and an oral presentation at the RANZCOG annual scientific meeting.

Main outcome measures: Self-reported frequency of antenatal screening for blood-borne viruses, change in practice based on a woman’s infection status, and advice given about risk of virus transmission via breastfeeding in Survey 2, compared with Survey 1.

Results: Survey 2 (response rate, 68%) found increases from the previous survey in the proportion of respondents reporting they always offered antenatal screening for HIV, from 51% to 59%, and for HCV, from 60% to 69% (P = 0.001 for both). For women with HIV infection, the proportion of respondents always recommending elective caesarean section increased from 37% to 49% (P = 0.001) and always avoiding rupture of membranes increased from 33% to 49% (P < 0.001). The proportion who reported advising (incorrectly) that breastfeeding is associated with increased risk of transmission to the infant decreased from 34% to 25% for HBV (P = 0.01) and from 47% to 39% for HCV (P = 0.03).

Conclusion: The frequency of antenatal testing for HIV and HCV is increasing in Australia. Knowledge about interventions to reduce mother-to-child transmission of HIV and knowledge of the risk of HBV and HCV transmission via breastfeeding improved after a relatively simple educational intervention.

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:

Methods
Education campaign

Following the 2002–2003 survey,2 we sent a two-page summary of its findings, and a comparison with published evidence and the current RANZCOG guidelines to all RANZCOG Fellows who had been mailed the original survey, irrespective of whether they had completed it. A colour brochure was also included, summarising recommended management during pregnancy for women infected with a blood-borne virus, and listing useful contacts for patients and clinicians. In addition, two review articles on HIV and HCV in pregnancy5,6 were published in the RANZCOG journal, which is distributed to all Fellows registered with the College, and the survey findings were presented at the RANZCOG annual scientific meeting in 2003.

Results

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.

Discussion

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.

Clinical management of labour for women with HIV or hepatitis C virus (HCV) infection reported by the 363 obstetricians who responded to both surveys

Women with HIV infection


Women with HCV infection


Question

Survey 1

Survey 2

Difference (%)* (95% CI of difference)

P

Survey 1

Survey 2

Difference (%)* (95% CI of difference)

P


Would you alter your clinical management and . . .

Offer elective caesarean section?

Always

135 (37%)

178 (49%)

12% (5%–19%)

0.001

5 (1%)

14 (4%)

3% (0.2%–5%)

0.04

Usually

58 (16%)

58 (16%)

0 (−5%–5%)

1.00

5 (1%)

11 (3%)

2% (−1%–4%)

0.14

Sometimes

36 (10%)

33 (9%)

−0.8% (−5%–3%)

0.71

30 (8%)

41 (11%)

3% (−1%–7%)

0.17

Rarely

30 (8%)

25 (7%)

−1% (−5%–2%)

0.48

104 (29%)

90 (25%)

−4% (−10%–3%)

0.25

Never

54 (15%)

22 (6%)

−9% (−10%–0.1%)

0.06

203 (56%)

190 (52%)

−4% (−12%–4%)

0.33

Don’t know

41 (11%)

37 (10%)

−1% (−6%–3%)

0.63

13 (4%)

12 (3%)

−0.3% (−3%–2%)

0.82

Avoid rupture of membranes?

Always

119 (33%)

176 (49%)

16% (10%–23%)

0.001

12 (3%)

28 (8%)

4% (1%–8%)

0.009

Usually

62 (17%)

65 (18%)

0.8% (−5%–6%)

0.77

51 (14%)

70 (19%)

5% (−0.1%–11%)

0.06

Sometimes

22 (6%)

21 (6%)

−0.3% (−4%–3%)

0.86

37 (10%)

49 (14%)

3% (−1%–8%)

0.17

Rarely

25 (7%)

18 (5%)

−2% (−5%–1%)

0.25

73 (20%)

68 (19%)

−1% (−7%–4%)

0.63

Never

75 (21%)

33 (9%)

−12% (−17% to −6%)

0.001

171 (20%)

131 (36%)

16% (10%–22%)

0.001

Don’t know

44 (12%)

35 (10%)

−3% (−7%–2%)

0.28

16 (4%)

11 (3%)

1% (−4%–1%)

0.32

Avoid fetal scalp electrodes?

Always

223 (61%)

258 (71%)

10% (3%–17%)

0.01

172 (47%)

177 (49%)

1% (−6%–9%)

0.71

Usually

54 (15%)

48 (13%)

−2% (−7%–3%)

0.51

90 (25%)

105 (29%)

4% (−2%–11%)

0.21

Sometimes

8 (2%)

4 (1%)

−1% (−3%–1%)

0.25

20 (6%)

16 (4%)

−1% (−4%–2%)

0.49

Rarely

1 (0.3%)

5 (1%)

1% (−0.2%–2%)

0.11

18 (5%)

15 (4%)

−0.8% (−4%–2%)

0.60

Never

27 (7%)

9 (3%)

−5% (−8% to −2%)

0.002

48 (13%)

34 (9%)

−4% (−8% to −0.8%)

0.95

Don’t know

34 (9%)

23 (6%)

−3% (−7%–1%)

0.12

10 (3%)

9 (3%)

−0.2% (−3%–2%)

0.11


* Difference = Survey 2 −Survey 1.

Received 13 November 2005, accepted 14 February 2006

  • Michelle L Giles1
  • Suzanne M Garland1
  • Sonia R Grover2
  • Sharon M Lewin3
  • Margaret E Hellard4

  • 1 Department of Microbiology and Infectious Disease, Royal Women's Hospital, Melbourne, VIC.
  • 2 Mercy Hospital for Women, Melbourne, VIC.
  • 3 Department of Infectious Diseases, The Alfred Hospital, Melbourne, VIC.
  • 4 Macfarlane Burnet Institute for Medical Research and Public Health, Melbourne, VIC.


Correspondence: michelle.giles@rwh.org.au

Acknowledgements: 

Michelle Giles has received support from the Centre for Clinical Research Excellence in Infectious Diseases, and Margaret Hellard from a National Health and Medical Research Council Career Development Fellowship and VicHealth Public Health Senior Researcher Fellowship.

Competing interests:

None identified.

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  • 2. Giles ML, Sasadeusz JJ, Garland SM, et al. An audit of obstetricians’ management of women potentially infected with blood-borne viruses. Med J Aust 2004; 180: 328-332. <MJA full text>
  • 3. The International Perinatal HIV Group. The mode of delivery and the risk of vertical transmission of human immunodeficiency virus type 1. N Engl J Med 1999; 340: 977-987.
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