2008 Publications

Coleman V.H., Carter M.M., Morgan M.A., & Schulkin J. (2008). United States Obstetrician-Gynecologists’ screening patterns for anxiety during pregnancy.  Depression and Anxiety, 25(2):114-23.

As obstetrician-gynecologists (ob-gyns) take on a greater role in women’s healthcare, it is important that they are aware of the high prevalence of anxiety disorders in their patient population. Anxiety disorders present during pregnancy can have detrimental effects on both mother and child. For example, preterm birth and behavioral inhibition in infants have both been associated with high anxiety during pregnancy. In the present study, we studied 1,193 ob-gyns on their screening rates, practice patterns, training, and knowledge as they relate to anxiety disorders during pregnancy. We achieved a 44% response rate (n=397) after three mailings. Physicians reported a moderate interest in screening for and diagnosing anxiety, but less interest in treatment. Only 20% of respondents (n=79) screen for anxiety during pregnancy, and they typically refer anxiety-disordered patients to mental health professionals. Ob-gyns with comprehensive or adequate training were significantly more likely to screen than those who stated that their training was inadequate. Having a friend who has been diagnosed with an anxiety disorder also significantly increased both the likelihood that these physicians would screen and the reported level of interest in screening, diagnosis, and treatment of anxiety disorders during pregnancy. At present, the majority of ob-gyns feels that their training in this area was barely adequate to inadequate. Specifically, generalized anxiety disorder may be the least understood. Increased training in this area would allow ob-gyns to overcome what they list as the primary barrier to anxiety screening during pregnancy—that is, inadequate training about anxiety disorders.

Power, M., Baron, J., & Schulkin, J. (2008). Factors associated with obstetrician-gynecologists’ response to the Women’s Health Initiative trial of combined hormone therapy. Medical Decision Making, 2007, 28(3):411-8. Epub 2008 May 13.

The Women's Health Initiative trial of combined estrogen and progestin (WHI E+P) ended prematurely after preliminary evidence indicated that harms exceeded benefits, with no cardiovascular benefit. There was controversy over the results and the decision to end the trial early, with many obstetrician-gynecologists expressing reservations about the evidence. The Research Department of the American College of Obstetricians and Gynecologists conducted a study regarding the WHI E+P, sending questionnaires to 2500 randomly selected Fellows; 703 Fellows returned usable surveys (28.1%). Despite almost universal awareness of the results of the WHI E+P (> 97%), almost half of the responding physicians did not find the results convincing and disagreed with the decision to stop the trial. In this further examination of the data, we identified characteristics of the respondents who were associated with either accepting or rejecting the WHI E+P. The year residency was completed, the relative importance a respondent attributed to randomized clinical trials (RCTs), concern about harms of action, and opinion of alternative therapies were significant factors. One of 5 respondents found the results convincing and agreed with the decision to end the trial (acceptors). One of 3 respondents did not find the results convincing and disagreed with the decision to end the trial (rejectors). Acceptors had completed residency more recently (1991 v. 1985, P = 0.001), rated evidence from RCTs as more important (P = 0.006), were more concerned with harms of action (22.4% v. 10.6%, P = 0.004), and were more likely to have a favorable opinion of alternative therapies to hormone therapy (64.1% v. 44.4%, P < 0.001).

Coleman, V.H., Morgan, M.A., Carlson, R., Hawks, D., & Schulkin, J.  (2008). Patient Perceptions of Obstetrician-gynecologists' Practices Related to HIV Testing.  Matern Child Health J , Jun 10. [Epub ahead of print]

Objectives: The objective of this study was to examine the beliefs and behaviors of pregnant and non-pregnant women about human immunodeficiency virus (HIV) and HIV testing, and to determine why some pregnant women do not have prenatal HIV testing.  Methods: Fifteen patient surveys, assessing beliefs and behaviors  related to HIV testing, were mailed to each of 687 obstetrician-gynecologists who are members of the Collaborative Ambulatory Research Network (CARN). Data are reported from 851 patient respondents (297 pregnant and 554 non-pregnant), and were analyzed utilizing independent samples t-tests, chi-square analysis, and linear regression.  Results: The majority of respondents (72%) reported that their current obstetrician-gynecologist never recommended HIV testing, although 65% reported having been tested for HIV at some point and 55% had received testing from their current obstetrician-gynecologist. Age, race, and pregnancy status predicted likelihood of patients receiving HIV testing recommendations, with young, pregnant, Hispanic, and African-American patients most likely to have had testing recommended. Among pregnant respondents specifically, three-fifths (61%) said their current obstetrician-gynecologists had never recommended HIV testing, although 82% reported having had an HIV test at some point. In contrast, almost all (98%) of responding physicians who practice obstetrics said they recommend HIV testing to all of their pregnant patients.  Additionally, most obstetrician-gynecologists report recommending, either strong (29%) or moderately (60%), HIV testing for non-pregnant patients who are sexually active and who have not had previous HIV testing.  However, 43% of non-pregnant patients reported that they have never been tested and 79% said their current obstetrician-gynecologist has never recommended testing.  Conclusion: Obstetrician-gynecologists and their patients differed significantly in their report of HIV testing recommendations offered.  Although there may be some confusion as to what is considered a "recommendation," efforts should be made to increase communication between obstetrician-gynecologists and their patients.

Anderson, B., Schulkin, J., Ross, D.S., Rasmussen, S.A., Jones, JL, Cannon M J (2008) Knowledge and practices of obstetricians and gynecologists regarding cytomegalovirus infection during pregnancy--United States, 2007.  MMWR 57: 65-68.

In the United States, congenital cytomegalovirus (CMV) infection occurs in approximately 1 in 150 live births, leading to permanent disabilities (e.g., hearing loss, vision loss, and cognitive impairment) in approximately 1 in 750 live-born children. A common mode of CMV transmission to a pregnant woman is through close contact with infected bodily fluids such as urine or saliva, especially from young children. Because no vaccine is available and treatment options are limited, renewed attention has been given to prevention of CMV infections among pregnant women through traditional infection-control practices, such as good hand hygiene. These practices have been encouraged by organizations such as CDC and the American College of Obstetricians and Gynecologists (ACOG), which recommend that obstetricians and gynecologists (OB/GYNs) counsel women on careful handling of potentially CMV-infected articles, such as diapers, and thorough hand washing after close contact with young children. Despite this increased emphasis on avoiding infection during pregnancy, few women are aware of CMV infection and how it can be prevented. During March-May 2007, ACOG surveyed a national sample of OB/GYNs to assess their knowledge and practices regarding CMV infection prevention. This report describes the results of that survey, which indicated that fewer than half (44%) of OB/GYNs surveyed reported counseling their patients about preventing CMV infection. These results emphasize the need for additional training of OB/GYNs regarding CMV infection prevention and for a better understanding of the reasons that physician knowledge regarding CMV transmission might not result in patient counseling.

Morgan, M.A.; Goldenberg, R.L.; Schulkin, J. (2008) Obstetrician-gynecologists’ practices regarding preterm birth at the limit of viability. The Journal of Maternal-Fetal and Neonatal Medicine,  21: 115-121.

Objectives: To assess obstetrician-gynecologists' judgments of gestational age of viability and earliest age of medical intervention for preterm delivery, and to associate these practice decisions with physician characteristics. Methods: Questionnaires were mailed to 1193 members of the American College of Obstetricians and Gynecologists (ACOG). Results: The response rate was 59%. The majority of respondents considered 24 weeks the earliest age a fetus is potentially viable (57%) and at which they would routinely perform cesarean section for fetal distress (58%). Those respondents who judged viability as 23 weeks or less were more likely to have been in practice for a shorter period (p < 0.05), be a maternal-fetal medicine specialist (p < 0.005), and be from southern or central states (p < 0.005). Similarly, those respondents who would not intervene for fetal distress until 26 weeks gestation were more likely to have been in practice for longer (p < 0.01), to have performed fewer deliveries (p < 0.05), to be in solo practice (p < 0.01), and not to be a maternal-fetal medicine specialist (p < 0.01); males and females did not differ when controlling for age (p = 0.552). Conclusion: Obstetrician-gynecologists' judgment of viability threshold is consistent with standard estimates of 24 weeks. Viability judgment and reported earliest age for routine intervention both differ by physician characteristics.

Anderson, B., Hale, R., Salsberg, E., Schulkin, J. (2008) Outlook for the future Obstetrician-gynecologist workforce, American Journal of Obstetrics and Gynecology, 99: 81-88.

Objective: The objective of the study was to assess the future physician workforce with a sample of obstetrician-gynecologists. Study Design: Two separate surveys regarding career satisfaction and retirement plans were sent to random samples of obstetrician-gynecologists under age 50 years (n = 2,000) and over the age of 50 (n = 2,100). Results: Obstetrician-gynecologists over the age of 50 years who were working part time or were female were more satisfied than those working full time or were male. Obstetrician-gynecologists (under and over age 50 years) who were concerned about liability and unable to balance their work and personal lives were more dissatisfied. Obstetrician-gynecologists retired earlier than planned because of rising malpractice costs and later than planned because of high career satisfaction. Conclusion: Low career satisfaction may be adding to the already shrinking physician workforce. Offering part-time work opportunities and alleviating liability concerns may increase career satisfaction and help to combat a future of the physician workforce shortage.

Morgan, M.A.; Goldenberg, R.L.; Schulkin, J. (2008) Obstetrician-gynecologists' screening and management of preterm birth.  Obstetrics and Gynecology , 2008 Jul;112(1):35-41.

Objective: To define obstetrician-gynecologists' screening for potential preterm birth risk factors and interventions they use when indicators suggest the patient may be at increased risk. Methods: Questionnaires were mailed to 1,193 American College of Obstetricians and Gynecologists members. Results: The response rate was 59%. Respondents most frequently report screening for previous preterm birth (98%) and cone biopsy (95%) as risk factors for preterm birth. Twenty-one percent do not screen for asymptomatic urinary tract infection and 57% screen for group B streptococci in an attempt to prevent preterm birth. Almost one third (31%) routinely recommend bed rest in twin pregnancies. Most (98%) use tocolytics (primarily magnesium sulfate, 94%) for women with intact membranes in preterm labor. Nearly 100% use corticosteroids in anticipated preterm births, and few (4%) repeat the dosing if delivery has not occurred within 1 week. Twenty-four percent of respondents did not have access to a newborn intensive care unit (ICU); they were more likely to refer a patient with an impending preterm delivery to a maternal-fetal medicine specialist for complete care than were those with a newborn ICU available (79% compared with 9%; P<.001). Conclusion: Most obstetrician-gynecologists are practicing in accord with current findings on preterm birth risk factors and interventions. However, there may be overscreening and underscreening for various infections and overuse of bed rest as a preterm birth intervention. When preterm birth is imminent, physicians often and appropriately seek the most specialized care possible for their patients. Level of Evidence: III.

Coleman, V.H., Carter, M.M., Morgan, M.A., Schulkin, J. (2008) United States obstetrician gynecologists’ accuracy in the simulation of diagnosing anxiety disorders and depression during pregnancy. Journal of Psychosomatic Obstetrics and Gynecology, 29(3):173-84.

The objective of this study was to examine obstetrician-gynecologists' diagnostic accuracy for mental health issues during pregnancy through utilization of clinical vignettes describing depressive and anxiety symptoms, as well as to explore factors associated with increased diagnostic accuracy and related practice patterns. Questionnaires were mailed to 1193 American College of Obstetricians and Gynecologists Fellows and Junior Fellows. The response rate was 44% after three mailings. Depression was correctly identified by over 90% of respondents, whereas significantly fewer correctly diagnosed panic disorder (55%) and generalized anxiety disorder (32%). Confidence ratings significantly predicted diagnostic accuracy in some cases. Approximately half of respondents reported referring anxiety disordered patients to a mental health professional. There may be an education gap in ob-gyns' diagnostic knowledge of anxiety disorders, which may addressed by increasing physician confidence in diagnosis through increased training.

Van Beneden CA, Hicks LA, Riley LA, & Schulkin J. (2008). Provider knowledge, attitudes and practices regarding obstetric and post-surgical gynecologic infections due to Group A Streptococcus and other infectious agents. Infectious Diseases in Obstetrics and Gynecology. 110, 1019-26.

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.

Morgan MA, Goldenberg RL, & Schulkin J. (2008). Obstetrician-gynecologists’ knowledge of preterm birth frequency and risk factors. The Journal of Maternal Fetal Neonatal Medicine, 20(12), 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.


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