Provider Perspectives on De-Implementation of Routine Blood Typing and Rh Immune Globulin Administration in the First...

To avoid the consequences of sensitization that can occur when people with Rh-negative blood are pregnant with Rh-positive fetuses and experience bleeding, obstetrician-gynecologists have historically administered prophylactic Rh immune globulin for any first trimester bleeding, including abortion and pregnancy loss. As the research base has evolved, many professional societies have changed their recommendations on the use of blood typing and Rh immune globulin administration for first trimester bleeding, but widespread practice has yet to change. We aimed to understand barriers to de-implementation of routine testing and prophylaxis for first trimester bleeding events from the perspective of obstetrician-gynecologist physicians.

We conducted qualitative in-depth interviews with obstetrician-gynecologists who provide first trimester pregnancy care. Guided by the Integrated Behavior Model and the Consolidated Framework for Implementation Research, we elicited participants' perceived barriers to de-implementation of routine Rh testing and Rh immune globulin prophylaxis for first trimester bleeding and suggestions for de-implementation strategies. Data were coded iteratively and analyzed thematically.

Twenty physicians completed interviews. Participants were based in 11 states and worked in settings that included teaching hospitals, freestanding abortion clinics, private practices, and the carceral system. Barriers to de-implementation included a lack of familiarity with evidence and limited time to engage in change initiatives. Although society guidance change was considered an essential component in discontinuing this longstanding practice, other drivers of practice change were reported to be additional studies on Rh sensitization in the first trimester, leadership support, and educational initiatives for providers and patients.

Obstetrician-gynecologists in this study favored de-implementation of routine blood typing and Rh immune globulin prophylaxis in first trimester bleeding but lacked sufficient support. Practice change becomes more likely when providers feel confident in their grasp of evidence, institutional leaders support change, and relevant professional societies are aligned in their guidance.