2003 Publications

Hankins G.D., Erickson K., Zinberg S., Schulkin J. Neonatal encephalopathy and cerebral palsy: a knowledge survey of Fellows of The American College of Obstetricians and Gynecologists. Obstetrics & Gynecology. 101(1):11-7, 2003 Jan.

Objective: To assess practicing obstetricians' knowledge of the etiology and pathophysiology of neonatal encephalopathy and its relationship to cerebral palsy. Methods: A questionnaire designed to test both knowledge and practice patterns was mailed to 413 members of the Collaborative Ambulatory Research Network of The American College of Obstetricians and Gynecologists (ACOG), as well as 600 randomly selected non-Network ACOG Fellows. The questionnaire was composed of 15 knowledge questions and three clinical scenarios containing seven knowledge questions. Six of the questions directly assessed knowledge of cerebral palsy. Results: Of those who returned the questionnaire, 351 practiced obstetrics and were included in the statistical analyses. For the majority of questions, "Don't know" was the most frequent response. The next most frequent response for 8/13 questions was the correct answer. Performance was strongest as regarded actual clinical practice and relatively weak regarding the antecedents of neonatal encephalopathy and cerebral palsy. The physicians' actual knowledge scores showed a significant correlation with their self-assessments of knowledge (r =.41, P <.001). The majority of physicians rated their training on this topic in medical school, residency, and through continuing medical education as marginal or inadequate. Conclusion: The results of this survey identified large knowledge gaps in this area, suggesting a need to develop educational projects to address these deficits by both professional organizations and individual teachers.

Jones J.L., Ogunmodede F., Scheftel J., Kirkland E., Lopez A., Schulkin J., Lynfield R. Toxoplasmosis-related knowledge and practices among pregnant women in the United States. Infectious Diseases in Obstetrics & Gynecology. 11(3):139-45, 2003.

Background: Infection with Toxoplasma gondii during pregnancy can lead to severe illness in the fetus. Many T. gondii infections are preventable by simple hygienic measures. Methods: We surveyed pregnant women in the US to determine their knowledge about toxoplasmosis and their practices to prevent infection. Volunteer obstetricians selected to be demographically representative of the American College of Obstetricians and Gynecologists recruited the participants. Results: Of 403 women responding to the survey, 48% indicated that they had heard or seen information about toxoplasmosis; however, only 7% were aware of being tested for the disease. Forty percent of responding women knew that toxoplasmosis is caused by an infection, but 21% thought that a poison causes it. The highest level of knowledge was about cats and T. gondii; 61% responded that the organism is shed in the feces of infected cats and 60% responded that people could acquire toxoplasmosis by changing cat litter. There was a low level of knowledge about other risk factors; only 30% of the women were aware that T. gondii may be found in raw or undercooked meat. Nevertheless, a high percentage of women indicated that they do not eat undercooked meat during pregnancy and that they practice good hygienic measures such as washing their hands after handling raw meat, gardening or changing cat litter. Conclusion: Except for the risk of transmission from cats, knowledge among pregnant women about toxoplasmosis is low. However, toxoplasmosis-preventive practices are generally good, suggesting that providers should continue to offer education about practices that help prevent foodborne diseases in general as well as information about preventing toxoplasmosis specifically.

Schrag S.J., Fiore A.E., Gonik B., Malik T., Reef S., Singleton J.A., Schuchat A., Schulkin J. Vaccination and perinatal infection prevention practices among obstetrician-gynecologists. Obstetrics & Gynecology. 101(4):704-10, 2003 Apr.

Objective: To assist efforts to improve adult vaccination coverage by characterizing vaccination and infectious disease screening practices of obstetrician-gynecologists. Methods: A written survey of demographics, attitudes, and practices was mailed to 1063 American College of Obstetricians and Gynecologists Fellows, including the Collaborative Ambulatory Research Network (n = 413) and 650 randomly sampled Fellows. Results: Seventy-four percent of Collaborative Ambulatory Research Network members and 44% of nonmembers responded. A majority (Collaborative Ambulatory Research Network members: 60%; nonmembers: 49%) considered themselves primary care providers. Fewer than 60% routinely obtained patient vaccination or infection histories. Most screened prenatal patients for hepatitis B surface antigen (89%) and rubella immunoglobulin G antibody (85%). Sixty-four percent worked in practices that offered at least one vaccine; the most common were rubella (52%) and influenza (50%). Ten percent worked in practices that offered all major vaccines recommended for pregnant or postpartum women. Despite recommendations to provide influenza vaccine to pregnant women during influenza season, only 44% did so; among those who did not, 14% reported a belief that pregnant women do not need influenza vaccine. Provision of vaccine was associated with working in a multispecialty practice (adjusted odds ratio [OR] 2.6, 95% confidence interval [CI] 1.6, 4.1) and identifying as a primary care provider (adjusted OR 1.9; 95% CI 1.3, 2.7). The most common reasons for not offering vaccines were cost (44%) and a belief that vaccines should be provided elsewhere (41%). Conclusion: The high proportion of obstetrician-gynecologists who do not offer vaccines or screen for vaccine and infection histories suggests missed opportunities for prevention of maternal and neonatal infections.

S pong C.Y., Erickson K., Willinger M., Hankins G.D., Schulkin J. Stillbirth in obstetric practice: report of survey findings. Journal of Maternal-Fetal & Neonatal Medicine. 14(1):39-44, 2003 Jul.

Objective: Stillbirth affects a large portion of the population and results in mortality rates comparable to those of preterm delivery and sudden infant death syndrome combined. Despite the large burden, little information is available to offer patients regarding etiology, treatment or prevention for a subsequent pregnancy. Methods: We surveyed a sample of Fellows of the American College of Obstetricians and Gynecologists to determine the practice patterns in the management of stillbirth. Results: The majority of Fellows agreed on the definition of stillbirth; however, their approach to treatment and prevention varied. A majority of Fellows believed that research on understanding stillbirth was of national importance. Conclusions: A comprehensive educational effort to include current knowledge regarding causes and management, standardized diagnostic procedures, death registration and case review is recommended to improve obstetric care of those with a stillbirth.

Dietrich A.J., Williams J.W.Jr., Ciotti M.C., Schulkin J., Stotland N., Rost K., Baram D., Cornell J. Depression care attitudes and practices of newer obstetrician-gynecologists: a national survey. American Journal of Obstetrics & Gynecology. 189(1):267-73, 2003 Jul.

Objective: The study was undertaken to assess attitudes and behavior of newer obstetricians/gynecologists in depression care. Study Design: One thousand randomly selected physicians in their final year of training or recent practice received a survey about depression: training; related attitudes, responsibility, confidence; and self-reported care for the last depressed patient. Results: Of those eligible, 437 (64%) returned the survey. Current residents reported more didactic mental health training, but practice patterns were similar to recent graduates. Overall, 94% felt responsible for recognition, whereas about half indicated asking about substance abuse, sexual abuse, or physical abuse, 37% expressed confidence in their ability to treat with medications, and 22% felt confident in their ability to manage depression overall. Conclusion: Residents are receiving more didactic mental health training, yet changes in training are not yet reflected in reported practice patterns or confidence. The use of antidepressant medications and assessment of contributing conditions such as abuse deserve more emphasis in training.

Boaz K., Fiore A.E., Schrag S.J., Gonik B., Schulkin J. Screening and counseling practices reported by obstetrician-gynecologists for patients with hepatitis C virus infection. Infectious Diseases in Obstetrics & Gynecology. 11(1):39-44, 2003.

Background: Obstetrician-gynecologists are important providers of primary health care to women, and the hepatitis C virus (HCV) infection screening practices and recommendations provided by obstetrician-gynecologists for HCV-infected patients are unknown. Methods: We surveyed American College of Obstetricians and Gynecologists (ACOG) Fellows, including 413 Fellows who were participating in the Collaborative Ambulatory Research Network (CARN) and 650 randomly sampled Fellows, about HCV screening and counseling practices. Results: In total, 74% of CARN members and 44% of non-CARN members responded. Demographics and practice structure were similar between the two groups. More than 80% of providers routinely collected drug use and blood transfusion histories from their patients. Of the respondents, 49% always screened for HCV infection when patients had a history of injection drug use, and 35% screened all patients who had received a blood transfusion before 1992. For HCV-infected patients, 47% of the physicians always advised against breastfeeding, 70% recommended condom use with a long-term steady partner, and 64% advised against alcohol consumption. Respondents who considered themselves to be primary care providers were no more likely to screen or provide appropriate counseling messages than were other providers. Conclusions: Most obstetrician-gynecologists are routinely collecting information that can be used to assess HCV infection risk, but HCV screening practices and counseling that are provided for those with HCV infection are not always consistent with current Centers for Disease Control and Prevention and ACOG recommendations.

Noller, K.L.,Bettes, B., Zinberg, S., Schulkin, J. Cervical Cytology Screening Practices Among Obstetrician–Gynecologists. Obstetrics & Gynecology, 102:259-265, 2003 Aug.

Objective: To estimate the current cervical cytology screening practices of American College of Obstetricians and Gynecologists (ACOG) Fellows, to establish a baseline for tracking future changes in practice.   Methods: Questionnaires were mailed to a random sample of ACOG Fellows (n = 599) and to a group of Fellows who have regularly participated in past ACOG surveys (n = 409). The questionnaires asked about current cytology screening and evaluation practices and presented clinical practice vignettes with additional questions. Descriptive statistical methods were used to evaluate the responses.   Results: Questionnaires were returned by 651 physicians (64.6%); 624 were complete. More than 94% of the respondents start cytology testing at age 18 years. Almost three fourths (74.2%) continue screening indefinitely. More than 80% use a liquid-based method of collection. Almost two thirds (65.1%) order human papillomavirus testing occasionally, usually (81.9%) for reports of atypical squamous cells of undetermined significance (ASCUS). Most Fellows in the sample perform colposcopy for an ASCUS result. Reports of atypical glandular cells resulted in variable approaches to further evaluation. Patient age and history were important variables for all test reports. Legal concerns were mentioned as important determinants of practice patterns. Conclusion:  In this sample of ACOG Fellows, most perform cervical cytology and evaluate abnormal results in accord with guidelines in place before the recommended changes in screening and evaluation were published in 2003.

Gabbe S.G., Morgan M.A., Power M.L., Schulkin J., Williams S.B. Duty hours and pregnancy outcome among residents in obstetrics and gynecology. Obstetrics & Gynecology. 102(5 Pt 1):948-51, 2003 Nov.

Objective: To assess the present status of resident duty hours in obstetrics and gynecology, identify existing policies concerning work schedules during pregnancy, and evaluate pregnancy outcome in female house officers. Methods: A questionnaire-based study was administered to residents taking the 2001 Council on Residency Education in Obstetrics and Gynecology examination. Results: More than 90% of the residents reported that their institution had a maternity leave policy. The leave was usually 4-8 weeks long and was paid. Nearly 95% of residents reported that they had to take over the work of residents on maternity leave. Most women residents worked more than 80 hours weekly throughout pregnancy, and few took time off before delivery. Most pregnancies occurred during the fourth year of training and did not seem to be adversely affected by the long work hours. Conclusion: This study, performed before the institution of the new Accreditation Council for Graduate Medical Education resident duty hour policies, demonstrated that, although women house officers continued to work more than 80 hours per week during pregnancy, most had a good pregnancy outcome. Nevertheless, there was a higher frequency of preterm labor, preeclampsia, and fetal growth restriction in female residents than in spouses or partners of male residents.

Contact:

Jay Schulkin, PhD
jschulkin@acog.org
 
Mike Power, PhD
mpower@acog.org
 
Greta Raglan
graglan@acog.org
 
Katherine Jones
kjones@acog.org