This paper reports a randomized controlled clinical trial of an intervention implemented in the context of usual prenatal outpatient care. The trial showed that pregnant women cared for by obstetricians who received an AD-based intervention were more likely to be screened for GBS than were those cared for by obstetricians who received printed guidelines only or no intervention. Similar results emerged when the three groups were taken as a cluster (pregnant women and their obstetricians), but the difference was not statistically significant, maybe because of low study power. The study was based on obstetrician members of a medical cooperative and the number of obstetricians and patients was relatively small. There was also loss of participant obstetricians on intention-to-treat analysis because 38 obstetricians did not conduct deliveries during the study period.
The AD intervention was associated with a significant increase of 9.5% in the frequency of prenatal GBS screenings compared with the passive printed material distribution or the no intervention scenario. This modest result for AD is in line with similar studies on guideline implementation
In the present study, when vaginal deliveries were analyzed separately, the proportion of screening was higher in the AD group (75%) than in the DM group (41.9%) and the C group (30.4%). These results suggest that the AD intervention was particularly relevant in women who had a vaginal delivery, for which prenatal GBS screening is the most useful in preventing neonatal infection.
The trial was conducted with obstetricians who had assisted a delivery paid for by the medical cooperative in the 3 months before the intervention, regardless of whether the obstetrician had requested GBS screening. The sample size was insufficient to analyze the effect of the intervention separately for obstetricians who had and had not previously requested screening. Because some studies have shown no impact of untargeted outreach visits
[18, 19], further studies should investigate the effect of AD on GBS screening separately for these two groups. Outreach visits may also face barriers in the form of resistance to change
, which should be assessed in future studies. Factors that most discourage the use of AD are time spent in the office for continuing medical education, physicians’ perception of wasting working time in the office to receive AD and continuing medical education provided by a non-physician
. The attitudes of the obstetricians were not assessed in the present study.
Another limitation of this trial is the relatively short follow-up of 3 months, which may have led to overestimation of the observed benefit of the intervention. Additionally, there is a possibility of contamination of the DM and C groups, but underestimation of the effect of AD is unlikely because the obstetricians worked in private medical outpatient practices and had relatively little interaction with each other.
In this trial, the educational visits were conducted by a trained physician, in line with a previous study that showed that visits made by peers tend to be more effective for behaviors related to collaboration with others and practice organization, compared with interventions conducted by non-peers
. However, interventions provided to obstetricians by other health professionals, such as nurses, should be examined in other studies.
This study has the potential to contribute to best practice, showing that a brief intervention based on AD in medical practice may have a significant impact in increasing the number of patients screened for GBS. This study is also relevant to obstetric practice in middle income economies such as Brazil where a significant proportion of the population receives care paid through private health insurance.
Several factors may prevent obstetricians following prenatal screening policy. Among these is the fact that there is a high rate of cesarean section in private clinics in Brazil (e.g. 83.3% in the present study), which may prompt obstetricians to consider the promotion of prenatal GSB screening unnecessary, especially for women already scheduled to undergo elective cesarean section. While the World Health Organization recommends a maximum of 15% cesarean sections among total births, Brazil has one of the highest cesarean section rates in the world, with a national average of 43%, reaching 80% in the private healthcare setting
. Although this is strongly related to higher social class, the main determinant of the elevated rate of cesarean section is delivery in a private maternity unit
[24, 25], as the sample studied here shows. The main reasons given by obstetricians are the convenience of programmed intervention for the obstetrician, uncertainty regarding the possibility of hypoxia or fetal trauma, and lack of preparation of the woman for the birth
The high cesarean section rate in the organization studied here may have played a role in the observed low impact of AD, as suggested by the finding that AD had a greater effect when women who underwent vaginal delivery were analyzed separately. The obstetrician’s decision to perform a cesarean section may have influenced his or her decision on whether to perform GBS screening because the aim of identifying women harboring GBS is to prevent neonatal colonization during vaginal delivery and not during cesarean section.
From the perspective of clinical practice in low resource settings, there may be gaps between the scientific evidence for an intervention and its adoption in clinical practice
, including a lack of financial and non-financial resources to implement changes in healthcare. The low remuneration of medical care is likely to contribute to the high rate of caesarean sections in Brazil, especially in the private health sector, whereas vaginal delivery requires more working hours and lower remuneration proportionally. Financial incentives may be effective in changing healthcare professional practice
. Although GBS testing is an easy and affordable screening method, the adoption of this practice is likely to be affected by the use of elective cesarean section. Further studies are needed to establish whether opting for a cesarean is a barrier to GBS screening. Advances in behavioral economics are driving efforts to use material or financial incentives to overcome economic obstacles or a lack of effective motivation, and recipients are incentivized to engage in health-related behaviors or practices with which they are already familiar and that they regard as beneficial or worthwhile.