From recommendations to practice: knowledge and implementation of infection screening in pregnancy among obstetricians and midwives in Italy

Introduction

The National Guidelines System (SNLG) of the Italian National Health Institute (Istituto Superiore di Sanità, ISS) is responsible for the development, updating, and validation of clinical practice guidelines in Italy, ensuring that recommendations are evidence-based and aligned with population health needs. 
In 2010, following a mandate from the Ministry of Health, the SNLG-ISS published the guideline ‘Uncomplicated Pregnancy’,¹ which became a key reference for the management of pregnancy in healthy women. In 2017, its recommendations were incorporated into the Essential Levels of Care, making them exempt from patient cost-sharing.
In December 2023, ISS released an updated version of the 2010 guideline1 to reflect emerging evidence and advances in clinical practice, with the aim of improving care quality and promoting evidence-based practice. This revision introduced several changes,² summarized in Table 1.

Notably, the updated guideline recommends screening for some infections, including Trypanosoma cruzi (T. cruzi, i.e., Chagas disease)³ and tuberculosis, while discontinuing other screenings, such as asymptomatic bacteriuria (ASB) and rubella. Additional updates concern screening recommendations for Cytomegalovirus (CMV),^4,5Treponema pallidum (T. pallidum, i.e., syphilis), hepatitis B (HBV), and hepatitis C (HCV).¹ 
To support healthcare professionals in adopting these updates, leading Italian obstetric and midwifery scientific societies, in collaboration with public institutions, organized a range of educational initiatives, including webinars and conferences, aimed at disseminating the updated recommendations. 
Despite these efforts, implementing updated recommendations consistently in clinical practice remains challenging. In this context, a recent study conducted by the group which conducted the present study evaluated healthcare professionals’ knowledge and attitudes regarding CMV screening before and after the publication of the 2023 updated ISS guideline. Using an online survey, only 30.1% of participants reported offering CMV screening in accordance with the updated recommendations.⁴ 

Objectives

The aim of this study was to evaluate the knowledge and practices of Italian obstetricians and midwives regarding infection screening modalities which were newly introduced, no longer recommended, or modified in the 2023 updated guideline on antenatal care for uncomplicated pregnancies.

Methods

Design

A nationwide, cross-sectional study was conducted using an anonymous online survey. Data were collected through electronic questionnaires distributed via major professional scientific societies in Italy.
This study was designed and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.⁶

Setting and participants

The survey was conducted between 15.11.2024 and 05.01.2025.
Voluntary convenience sample was used to recruit qualified obstetricians and midwives practicing in Italy through the Italian Society of Gynaecology and Obstetrics (SIGO), the National Federation of Midwifery Profession (FNOPO), and the Italian Society of Prenatal Medicine (SIMP), who acted as gatekeepers. Potential participants received an informative email including a participant information sheet and a link to provide informed consensus and access the survey.
Approximately 20,000 healthcare professionals were reached through the participating scientific societies, including about 16,700 members of FNOPO, approximately 3,000 members of SIGO, and 250 members of SIMP. Potential overlap between mailing lists, particularly between members of SIGO and SIMP, was anticipated. Therefore, the invitation email explicitly requested recipients to complete the survey only once. Nevertheless, the exact number of unique recipients could not be determined, precluding calculation of a precise response rate. To maximize participation, reminder emails were sent every three weeks, for a total of three reminders during the recruitment period. The questionnaire consisted of 10 multiple-choice items and 2 open-ended questions, divided into two sections. The first section collected sociodemographic information, including profession, years of experience, workplace, and Region of practice. The second section focused on items related to the 2023 ISS guideline on antenatal care for uncomplicated pregnancy, particularly screening and prevention practices for seven infectious conditions: Chagas disease, tuberculosis, ASB, rubella, syphilis, HBV, and HCV. Questions on CMV screening were excluded, as they had been addressed in a prior study.⁴ 
The survey was developed by a multidisciplinary panel of experts in maternal-foetal medicine, infectious diseases, and public health. Before its distribution, the questionnaire was pilot-tested in a small sample of the target population to evaluate comprehensibility and clarity. Minor revisions were made based on participants’ feedback. The full questionnaire is available as online Supplementary Material. Study data were collected and managed using Microsoft Excel.

Results

A total of 606 healthcare providers completed the survey, 311 (51.3%) of whom were obstetricians and 295 (48.7%) were midwives. 
Nearly half of the participants (N. 283; 46.9%) had more than 20 years of professional experience, and one third (N. 196; 32.3%) worked in secondary care settings. Overall, 359 respondents (59.1%) were employed in Northern Italy. Demographic and professional characteristics are reported in Table 2.

None of the professionals completing the survey answered all questions correctly regarding the screening modalities for the seven assessed infections (Figure 1). Of note, the lowest rates of answers aligned with the updated recommendations were observed for T. pallidum and HBV screening (8.1% and 4.8%, respectively). 
Detailed results for each type of screening test are presented in Figure 1. 

Newly recommended screening tests

Chagas disease

Only 11.5% (69/601) of the respondents to the questions regarding T. cruzi screening in pregnancy answered correctly; 66.7% (N. 46) were obstetricians and 47.8% (N. 33) worked in secondary care settings. In turn, 88.5% (532/601) of healthcare professionals did not follow the 2023 guideline recommendations, with 85.5% (456/532) not offering the screening at all, even in the presence of risk factors.

Tuberculosis

The majority of the respondents (81.9%; 494/603) reported not performing tuberculosis screening during pregnancy, whereas 1.81% (11/603) offered the screening incorrectly. Among the 98 (16.3%) participants who answered correctly, 66.3% (65/98) were obstetricians, 40.8% worked in a second-level hospital, and 64.3% were employed in a region of Northern Italy.

No longer advised screening tests

ASB

Only 14.1% (85/604) of respondents correctly refrained from offering ASB screening during pregnancy, in line with the updated guideline. Awareness of this recommendation was slightly higher among midwives (54.1%; 46/85) and those working in community settings (31.8%, 27/85). Conversely, 85.9% (519/604) of respondents continued to offer ABS screening, with 43.5 % (226/519) prescribing urine culture at both the first antenatal visit and again in the third trimester.  

Rubella

Among the 603 professionals responding on Rubella screening, only 68 (11.3%) reported correctly that the screening should not be offered, as recommended by the 2023 ISS guideline. Of these, 54.4% (37/68) were obstetricians and 38.2% (26/68) were employed in secondary-care settings.
Among the remaining 535 (88.7%) healthcare providers who answered to offer the screening, 490 (91.6%) prescribed serology during the first trimester, regardless of maternal vaccination status. Of note, 251 of these 535 respondents (46.9%) providing a wrong answer had more than 20 years of professional experience.

Modified screening tests

Syphilis

Only 49 healthcare providers (8.1%) answered questions regarding T. pallidum screening aligned with update recommendations. Among these, 55.1% (27/49) were obstetricians, 22.9% (11/49) worked in secondary-care settings, and 67.3% (33/49) were employed in Northern Italy. Among the 555 of 604 respondents who did not follow the updated recommendations, 87.0% (483) reported testing in both the first and the third trimesters, predominantly using non-treponemal assays (VDRL, RPR) rather than treponemal-specific antibody tests. Nearly half (46.8%, 260/555) had over 20 years of professional experience and 49% (272/555) were obstetricians.

HBV

HBV screening was offered in accordance with the updated guideline by only 4.8% (29/607) of respondents. Among these, the majority were obstetricians (22/29), 19/29 practicing in Northern Italy, and 14/29 working in secondary-care settings. Conversely, almost all providers (95.2%; 578/607) answered to offer HBV screening without adhering to the 2023 ISS guideline. Among these, 44.8% (259/578) recommended testing in both the first and third trimester using HBsAg assays, regardless of vaccination status. Nearly half of non-adherent providers (46.9%; 271/578) had more than 20 years of professional experience and 31.3% (181/578) worked in secondary-care hospitals. Regarding HBV vaccination in pregnancy, 94.3% (566/600) of respondents reported lacking confidence in prescribing it; specifically, 47% (266/566) did not offer HBV vaccination during pregnancy, while 53% (300/566) prescribed it incorrectly.

HCV

Ninety-one out of 603 respondents (15.1%) answered to correctly prescribe HCV screening according to the updated ISS guideline, with 84.8% (59/91) of them being obstetricians. Among the 512 (84.9%) professionals who answered incorrectly, 375 (73.2%) reported offering the test in both the first and the third trimester of pregnancy.  

Discussion

This survey was conducted approximately one year after the ISS published the updated guideline on antenatal care for uncomplicated pregnancy, which included revised recommendations for the screening of several infectious conditions.¹ 
Although respondents from Northern Italy were relatively overrepresented (59.1%), this distribution likely reflects, at least in part, the higher concentration of healthcare professionals and tertiary maternity centres in Northern regions, as well as differences in the dissemination of the survey through participating scientific societies. Nevertheless, this imbalance may limit the generalizability of the findings and has been acknowledged as a study limitation.
The study followed extensive dissemination efforts by leading Italian obstetric and midwifery scientific societies, in collaboration with public institutions, to raise awareness and promote guideline implementation in clinical practice.
Despite these initiatives, the findings of this study indicate low knowledge of and suboptimal adherence to the 2023 recommendations on infection screening in pregnancy. None of the respondents answered all questions correctly regarding screening modalities for the seven assessed infections and, for each infection, fewer than 20% of participants provided answers in line with the updated ISS recommendations. 
Answers did not aligned with the updated recommendations were most commonly due to continued adherence to the recommendations included in the previous 2010 edition of the ISS guideline.² Notably, many respondents reported using of non-treponemal assays (VDRL, RPR) for syphilis screening – practice endorsed in 2010, but no longer recommended in the 2023 update. Similarly, several healthcare professionals continued to prescribe screening tests that are no longer recommended, such as screening for ASB or rubella regardless of vaccination status. In addition, providers demonstrated limited knowledge of newly introduced screening, including Chagas disease and tuberculosis. Overall, these findings suggest persistent reliance on outdated guidance in clinical practice; however, this may also reflect the influence of non-updated local institutional protocols, organizational constraints, and limited resource availability.
Differences in knowledge were observed according to professional role and care setting. 
Obstetricians appeared to be more familiar than midwives with updated recommendations for HBV and HCV (>75%) and for Chagas disease and tuberculosis (>65%); also, they showed slightly higher knowledge regarding Rubella and syphilis screening (>54%). In turn, midwives showed greater knowledge of updated recommendations for ASB screening (>54%). These findings are particularly relevant given the increasing role of midwifes in managing uncomplicated pregnancies over the last decade, and may indicate heterogeneity in guideline dissemination across professional groups.
Higher knowledge of the updated guideline was observed among healthcare professionals working in secondary-care hospitals. This may reflect the higher prevalence of university-affiliated centres in these setting, where continuing medical education, academic teaching, and multidisciplinary meetings on emerging topics are more routinely integrated into clinical practice. Overall, translating updated recommendations into consistent clinical practice remains a major challenge. 
Clinicians generally support clinical practice guidelines and recognize their value in improving care quality.⁷ However, a substantial proportion of respondents reported screening practices that are not aligned with current recommendations. This behaviour likely reflects gaps not only in knowledge, but also in operational implementation.
Similarly, a study conducted in United Kingdom reported non-compliance by healthcare professionals with the recommendation against screening for ASB in pregnancy by the National Institute for Health and Care Excellence.⁸ 
More broadly, guideline uptake is influenced by multiple factors, including clarity of recommendations, accessibility, and  professional education.⁹ 
Ojo and their colleagues observed suboptimal adherence to syphilis screening recommendations in Indianapolis: only 27% of high-risk women were tested and 9% were tested only at delivery, despite the recommendation in favour of screening by the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists. Providers were more likely to test women with government-issued insurance, and who had a preterm delivery, resided in high-risk areas, and self-identified as Black, highlighting the influence of sociodemographic and contextual factors on guideline implementation in clinical practice.¹⁰
Among strategies to improve adherence, educational interventions specifically targeting healthcare professionals appear to be among the most effective.¹¹ However, because exposure to dissemination or educational initiatives was not assessed in the present study, no conclusions can be drawn regarding their impact on the observed findings.

Conclusions

Clinical guidelines represent an essential step toward evidence-based care, but their impact depends on multiple factors, including effective dissemination, local implementation strategies, organizational support, and the regular updating of institutional protocols. Further studies are needed to identify the barriers and facilitators influencing the adoption of updated recommendations and to inform interventions aimed at improving guideline-concordant clinical practice.

Conflicts of interest: none declared.

References

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