2007 Publications

Bettes, B.A., Coleman, V.H., Zinberg, S., Spong, C.Y., Portnoy, B., & Schulkin, J. Cesarean delivery on maternal request. Obstetrics and Gynecology, 109:57-66, 2007, Jan

Objective: To examine obstetrician–gynecologists’ knowledge, opinions, and practice patterns related to cesarean delivery on maternal request. Methods: Questionnaires were mailed to 1,031 American College of Obstetricians and Gynecologists Fellows in February 2006, with a response rate of 68%. The questionnaire queried respondents’ demographic characteristics, practices and attitudes surrounding vaginal and cesarean deliveries, knowledge and beliefs regarding the risks and benefits of elective and nonelective cesarean delivery, and counseling practices and department policies for cesarean delivery on maternal request. Results: About half of respondents believe women have the right to cesarean delivery on maternal request, and a similar percentage acknowledge having performed at least one cesarean delivery on maternal request. Fifty-eight percent of respondents note an increase in patient inquiries regarding cesarean delivery over the past year, yet most of their practices do not have a policy regarding this procedure. Respondents attribute the increase in inquiries to the increase of information from the media and to convenience. Respondents cited more risks than benefits of cesarean delivery on maternal request, and nearly all discuss these risks with patients who are considering one. Females were more negative toward cesarean delivery on maternal request than males and endorsed more risks and fewer benefits. There were no relationships between assessment of risks and benefits or practice with clinician age or patient characteristics. Conclusion: Most obstetrician–gynecologists in this study recognized an increased demand for cesarean delivery on maternal request within their practices, while believing that the risks of this procedure outweigh the benefits. Clinicians would benefit from strong evidence regarding risks and benefits, evidence that is crucial to guiding policy making with regard to cesarean delivery on maternal request.

Power, M.L., Schulkin, J., & Rossouw, J. Evolving practice patterns and attitudes with regard to hormone therapy by obstetrician gynecologists, Menopause, 14:20-38, 2007 Jan-Feb.

Objective: The objective of this study was to examine the opinions and prescribing practices of obstetrician-gynecologists regarding hormone therapy (HT) and the results from the Women's Health Initiative. Design: Surveys were sent to 2,500 randomly selected American College of Obstetrics and Gynecology fellows during December 2004 to March 2005; their responses are compared with those from a survey conducted in November to December 2003. Results: Respondents remained skeptical of the combined HT results (49.1% did not find the results convincing). Compared with the 2003 survey, men were more skeptical (58.8% did not consider the findings convincing in 2004 vs 53.4% in 2003, P = 0.045), and women were somewhat less skeptical (39.5% did not consider the findings convincing in 2004 vs 45.3% in 2003, P = 0.056). There was less skepticism about the estrogen-only trial, although 4 of 10 did not find the results convincing. Men were more skeptical than women; a majority of men disagreed with the decisions to stop the trials. Physicians who completed their residency more recently were more likely to accept the trial results. Respondents reported a reduction in HT prescription practice relative to the year 2000, but 62.7% reported they did not expect their prescribing practices to change further in the near future. The proportion of respondents who considered alternative therapies to HT as viable treatment options increased between 2003 and 2004 (37.1% vs 28.1%, P < 0.001). There was strong support for the use of HT for vasomotor symptoms, vaginal dryness, and osteoporosis, but most physicians did not consider HT useful for cardiovascular disease or dementia. Conclusions: Many obstetrician-gynecologists continue to express skepticism about the results and conduct of the Women's Health Initiative trials. The survey could not determine the reasons for skepticism.

Bailit, J.L., Schulkin, J., & Dawson, N.V. Risk-adjusted cesarean rates: What risk factors for cesarean delivery are important to practicing obstetricians. Journal of Reproductive Medicine, 52:194-198, 2007, Mar.

Objective: To determine which primary cesarean delivery risk factors are important to practicing physicians. Study Design: A sample of current members of the American College of Obstetrician Gynecologists were surveyed about the risk factors for primary cesarean delivery that they thought were most important. Data on demographic and practice characteristics were also collected. Sample size was determined by theoretical saturation. Results: Theoretical saturation was reach at 60 responses. A total of 290 surveys were returned. The 10 most common factors listed by physicians as preexisting patient risk factors for primary cesarean delivery were, in descending order of importance, medical problems, maternal obesity, macrosomic infant, malpresentation, multiple gestation, maternal age, Bishop score, patient's fear, preterm labor, and postdate pregnancy. Six of the 10 factors listed by respondents are in previously published risk-adjustment models. Conclusion: Our study suggested that the addition of obesity and birth weight to previously published risk-adjustment models should improve representation of practicing obstetricians' views.

Coleman, V.H., Laube, D.W., Hale, R.W., Williams, S.B., Power, M.L., & Schulkin, J. Obstetrician-gynecologists and primary care: training during residency and current practice patterns. Academic Medicine, 82:602-607, 2007, Jun.

Purpose: To assess obstetrician–gynecologists’ perceptions of their residency training in primary care, document health issues assessed at annual visits, and identify practice patterns of both generalist and specialist obstetrician–gynecologists. Method: Questionnaires were mailed to a random sample of 1,711 American College of Obstetricians and Gynecologists Young Fellows in September 2005. Information was gathered on perceptions about adequacy of residency training, how well training prepared obstetrician–gynecologists for current practice, and typical practice patterns for various medical diagnoses. Data were analyzed using univariate analysis of variance, t tests, and chi-square tests. Results: Of 935 respondents (55% response rate), physicians estimated that 37% of private, nonpregnant patients rely on them for routine primary care. Approximately 22% report that they needed additional primary care training, specifically for metabolism/nutrition and dermatologic, cardiovascular, and psychosexual disorders. A wide range of topics, except for immunizations, were typically discussed at annual visits. Patients with pulmonary diseases, vascular diseases, and nongenital cancers were most often referred to specialists, whereas patients with urinary tract infections, sexually transmitted infections, or who are menopausal are most often managed totally. Self-identification as a generalist or specialist was associated with some practice patterns. Respondents were neutral about the role of primary care in obstetrics–gynecology residency training.

Shaer, C.M., Chescheir, N., & Schulkin, J. Myelomeningocele: A review of the epidemiology, genetics, risk factors for conception, prenatal diagnosis, and prognosis for affected individuals. Obstetrical and Gynecological Survey, 62:1-9, 2007 Jul.

Although the use of folic acid before conception decreases the chance that a fetus will have an open neural tube defect, this condition still affects 0.5-1.0/1000 pregnancies in the United States. Results of a recent survey suggest that there are gaps in obstetrician-gynecologists' knowledge of risk factors for conception, strategies for prenatal diagnosis, and prognosis for affected individuals. To address these gaps this paper reviews the epidemiology, genetics, risk factors for conception, prenatal diagnosis, and prognosis for affected individuals, presents current information, and makes suggestions for expanding obstetrician-gynecologists' knowledge of myelomeningocele. Target Audience: Obstetricians & Gynecologists, Family Physicians  Learning Objectives: After completion of this article, the reader should be able to state that despite a large amount of professional and public education on the use of folic acid in prevention of open neural tube defects (ONTDs) the incidence still affects 0.5-1.0/1000 pregnancies and recall that a recent survey conducted by the ACOG shows substantial misunderstanding and misinformation on major categories of neural tube birth defects.

Noll, J.G., Schulkin, J., Trickett P.K., Susman, E.J., Breech, L., & Putnam, F.W.  Differential pathways to preterm delivary for sexually abuse and comparison women. Journal of Pediatric Psychology, 2007, Jun.

Objective: Two distinct conditions, Hypothalamic Pituitary Adrenal (HPA) axis disruptions and maternal alcohol use, have been linked to preterm delivery. These conditions have also been cited as potential sequelae of childhood abuse. Studies have linked childhood abuse to increased rates of preterm delivery but mechanisms explaining this association are unclear. Methods: This prospective study compared preterm birth rates across offspring born to mothers who were sexually abused in childhood (OA; N = 67) and offspring born to nonabused comparison mothers (OC; N = 56). Results: Preterm delivery rates were higher for the OA group (Odds = 2.80 ± 1.44, p < .05). Maternal prenatal alcohol use mediated this relationship, but HPA axis functioning did not. Heightened maternal cortisol was significantly related to preterm status, but only for the OC group. Conclusions: Results support the hypothesis that childhood abuse is a risk-factor for preterm delivery, however pathways are likely different for women with and without histories of sexual abuse.

Cleary-Goldman, J., Bettes, B., Robinson, J.N., Norwitz, E., & Schulkin, J.  Thrombophilia and the obstetric patient.  Obstetrics & Gynecology.  110(3):669-74, 2007 Sep.

Objective: To examine how practicing obstetricians evaluate and manage thrombophilias in selected clinical situations. Methods: A questionnaire investigating knowledge and practice patterns pertaining to thrombophilia was mailed to 300 randomly selected American College of Obstetricians and Gynecologists Fellows and Junior Fellows in February 2005.  Results:  Approximately 50% (151) of questionnaires were returned. Statistical analysis focused on the 104 responding obstetricians. The majority (greater than 70%) know which thrombophilias are inherited and which are acquired. More than 50% send an inherited thrombophilia panel and antiphospholipid antibodies on patients with a history of fetal demise, intrauterine growth restriction (less than 5th percentile), abruption, and severe preeclampsia. Ninety-two percent test patients with recurrent miscarriages for antiphospholipid antibodies. Despite no clear evidence, 80% also test these patients for inherited thrombophilias. The majority intervene with either thromboprophylaxis or low-dose aspirin when managing patients at risk for thromboembolism. Seventy percent use low-molecular-weight (fractionated) heparin for patients requiring therapeutic anticoagulation, while 62% also use it for prophylactic anticoagulation. Thirty-eight percent of physicians using low-molecular-weight (fractionated) heparin monitor anti-factor Xa levels. The majority (56%) felt their residency training with regard to thrombophilia was barely adequate. Only 8% felt their training was comprehensive, while 36% felt it was adequate.  Conclusion:  Most responding obstetricians do not manage thrombophilia patients according to expert opinion. Despite the fact that often there is no clear evidence for treatment, many physicians are inclined to intervene in patients at risk for thromboembolism. Educational endeavors are needed to guide obstetricians caring for patients at risk for thromboembolism.

Krueger, A., Schulkin, J., & Jones, J. Survey of obstetrician-gynecologists about Giardiasis. Infectious Diseases in Obstetrics and Gynecology. Article ID 21261, 6 pages, 2007. doi:10.1155/2007/21261

Giardiasis is one of the most common parasitic diseases in the United States with over 15,400 cases reported in 2005. A survey was conducted by The American College of Obstetricians and Gynecologists (ACOG) in collaboration with the Centers for Disease Control and Prevention (CDC) to evaluate the knowledge of obstetricians and gynecologists regarding the diagnosis and treatment of giardiasis. The questionnaire was distributed to a random sample of 1200 ACOG fellows during February through June of 2006. Five hundred and two (42%) responded to the survey. The respondents showed good general knowledge about diagnosis, transmission, and prevention; however, there was some uncertainty about the treatment of giardiasis and which medications are the safest to administer during the first trimester of pregnancy.

Power M.L., Milligan L.A., & Schulkin J. Management of Nausea and Vomiting of Pregnancy by Obstetrician-Gynecologists: A Survey.  The Journal of Reproductive Medicine.  52(10):922-8, 2007.

To assess obstetrician-gynecologists’ treatment of nausea and vomiting of pregnancy and to compare with recommendations from a published ACOG evidence-based Practice Bulletin, a survey questionnaire was mailed to the 1,075 ACOG Fellows who comprise the Collaborative Ambulatory Research Network. The most frequently recommended treatments for a patient with moderate to severe nausea with occasional vomiting were: eat frequent small meals (93 %), snacking on soda crackers (68.5%), and prescribing vitamin B6 plus doxylamine (67.1%). Two of three (66.7%) respondents had read the ACOG Practice Bulletin; almost all found it helpful (67.0%) or very helpful (29.5%). Respondents who had read the ACOG Practice Bulletin were generally more willing to treat nausea and vomiting of pregnancy aggressively. They were more likely to be aware that early treatment is recommended to prevent progression to hyperemesis gravidarum, and more likely to recommend the use of ginger (59.7% versus 47.9%, P = .014), and to prescribe vitamin B6 (84.1% versus 73.8%, P = .005) and Vitamin B6 plus doxylamine (70.9% versus 59.3%, P = .009). Obstetrician-gynecologists treatment and prescribing practices generally follow ACOG recommendations; the ACOG Practice Bulletin appears to have affected practice and knowledge.

Gray, A.D., Carlson, R., Morgan, M.A., Hawks, D., & Schulkin, J. Obstetrician-gynecologist’s knowledge and practice regarding HIV screening.  Obstetrics & Gynecology. 110(5): 1019:26, 2007. 

Objective: To gather more information regarding prenatal human immunodeficiency virus (HIV) testing by examining the practice patterns of obstetrician-gynecologists. Methods: Survey questionnaires were sent to 1,032 American College of Obstetricians and Gynecologists (ACOG) Fellows and Junior Fellows in practice. Questionnaires included inquiries about obstetrician-gynecologist characteristics, testing practices, and knowledge regarding HIV screening. Results: A total of 582 surveys (56%) were returned. We found that 1) most (97%) obstetrician-gynecologists reported recommending HIV testing to all of their pregnant patients; 2) almost half (48%) of the physicians reported using the opt-out approach to prenatal HIV testing; 3) respondents were sometimes unaware of whether their state requires recommending HIV testing during pregnancy. Conclusions: The finding that some obstetrician-gynecologists are unaware of their state regulations regarding prenatal HIV testing suggests that they would benefit from an increased awareness of state laws and regulations and having timely access to these requirements. The finding that most obstetrician-gynecologists offer HIV testing to all of their pregnant patients is consistent with the literature regarding prenatal HIV screening and with federal and national recommendations. However, study results also suggest that obstetrician-gynecologists may benefit from additional information to increase knowledge and strengthen perinatal HIV testing practice patterns.

Morgan, M.A., Goldberg, R.L., & Schulkin, J.  Obstetrician-gynecologists' knowledge of preterm birth frequency and risk factors.  The Journal of Maternal-Fetal & Neonatal Medicine, 20: 895-901.

Objectives: To assess obstetrician-gynecologists' knowledge of preterm birth, including prevalence, risk factors, and utility of various tests in predicting increased risk. Methods: A questionnaire was mailed to 1193 members of the American College of Obstetricians and Gynecologists. Results: The response rate was 59%. The majority of respondents were familiar with basic preterm birth prevalence rates. However, 21% underestimated the proportion of women with presumptive preterm labor in whom preterm birth will not occur. The majority (55%) overestimated the proportion of preterm births accounted for by multiples. Twelve percent indicated bed rest as a proven method for improving newborn outcome. Respondents were fairly accurate as to which factors produce the biggest increased risk of spontaneous preterm labor or rupture of membranes; however, they tended to overestimate the risk associated with smoking, hypertension, and non-gestational diabetes. They tended to underestimate, or were unsure of, the predictive value of positive fetal fibronectin (fFN) test results or short cervical length. Conclusions: Obstetrician-gynecologists' basic knowledge concerning preterm birth prevalence and risk factors was adequate. However, they tended to overestimate the risk associated with various maternal factors and underestimate the predictive value of various test results.

Van Beneden, C.A., Hicks, L.A., Riley, L.E., & Schulkin J.  Provider knowledge, attitudes, and practices regarding obstetric and postsurgical gynecologic infections due to group A Streptococcus and other infectious agents.  Infectious Diseases in Obstetrics and Gynecology, 90: 189-194.

Background: Knowledge, attitudes, and practices of obstetricians and gynecologists regarding the Centers for Disease Control and Prevention (CDC) recommendations for prevention of healthcare-associated group A streptococcal (GAS) infections as well as general management of pregnancy-related and postpartum infections are unknown. Methods: Questionnaires were sent to 1300 members of the American College of Obstetricians and Gynecologists. Results: Overall, 53% of providers responded. Postpartum and postsurgical infections occurred in 3% and 7% of patients, respectively. Only 14% of clinicians routinely obtain diagnostic specimens for postpartum infections; providers collecting specimens determined the microbial etiology in 28%. Microbiologic diagnoses were confirmed in 20% of postsurgical cases. Approximately 13% and 15% of postpartum and postsurgical infections for which diagnoses were confirmed were attributed to GAS, respectively. Over 70% of clinicians were unaware of CDC recommendations. Conclusions: Postpartum and postsurgical infections are common. Providing empiric treatment without attaining diagnostic cultures represents a missed opportunity for potential prevention of diseases such as severe GAS infections.


Jay Schulkin, PhD
Mike Power, PhD
Britta Anderson, PhD
Greta Raglan
Katherine Jones