2009 Publications

Leddy MA, Anderson BL, Gall S, Schulkin J. Obstetrician-gynecologists and the HPV vaccine: practice patterns, beliefs, and knowledge. J Pediatr Adolesc Gynecol. 2009;22(4):239-246.

Study Objective: Human papillomavirus (HPV), the most common sexually transmitted infection in the United States, can be contracted by young girls shortly after sexual debut. Human papillomavirus can lead to cervical and anogenital cancers and genital warts. A vaccine has been developed to protect against precancerous lesions. We examined obstetrician-gynecologists' practices, opinions, and knowledge regarding this vaccine. Design: A 37-item questionnaire was sent out by the American College of Obstetricians and Gynecologists (ACOG) to its fellows and junior fellows between May and November of 2007. Participants: Surveys went to 3896 fellows and junior fellows of ACOG. Of these surveys, 771 were Collaborative Ambulatory Research Network (CARN) members who have volunteered to receive several surveys per year. The remaining 3125 questionnaires were sent to all fellows and junior fellows in ACOG's District V (Ohio, Kentucky, Indiana, Michigan and Ontario, Canada). Response rates were 51.0% and 30.7% for CARN and District V, respectively. Results: Of those who administer vaccines, most offer the HPV vaccine. Most know this vaccine protects against 4 HPV types. Fewer knew the percentages of cervical cancers and genital warts prevented. Over 20% knew all 3 answers. Only a minority answered all incorrectly. Approximately 15% view HPV vaccine as safe in pregnancy. Many agree cost is a reason for patient refusal and a deterrent from mandating the vaccine. Conclusion: Obstetrician-gynecologists are knowledgeable of the HPV vaccine and are incorporating it into practice. Financial concerns may limit widespread immunization.

Anderson BL, Stumpf P & Schulkin J. Medical error reporting, patient safety and the physician. Journal of Patient Safety. 2009;5(3):176-179.

Objectives: To shed light on factors that may help explain inaccurate medical error reporting and do not receive much attention: ob-gyns' comfort with reporting medical errors and personal experience with being injured while receiving medical care.  Methods: Questionnaires were sent to a total of 600 members of the American College of Obstetricians and Gynecologists between September and December 2006. The questionnaire included demographics and three questions about practice patterns and opinions about patient safety: (1) How comfortable are you reporting medical errors? (2) Have you or a friend/family member ever been injured while receiving medical care? (3) How frequently do you witness medical errors?  Results: A 53.2% response rate was obtained. Only 56.3% of ob-gyns "felt free" to frequently report medical errors, with no differences by sex or age. One in 5 (20.8%) reported that they or a family member had been injured by a medical error. Ob-gyns who reported that they or a friend or family member had been injured during medical care more frequently reported witnessing medical errors.  Conclusions: Our results show that many physicians do not feel free to report errors. Research on the decision making of physicians (e.g., person-who effect, regret avoidance, and the availability heuristic) may provide useful insights to problems with medical error reports.

Anderson BL, Silverman GK, Loewenstein G, Zinberg S, & Schulkin J. Factors Associated With Physicians' Reliance on Pharmaceutical Sales Representatives. Academic Medicine. 2009;84(8):994-1002.

Purpose: To examine relationships between pharmaceutical representatives and obstetrician-gynecologists and identify factors associated with self-reported reliance on representatives when making prescribing decisions.  Methods: In 2006-2007, questionnaires were mailed to 515 randomly selected physicians in the American College of Obstetricians and Gynecologists' Collaborative Ambulatory Research Network. Participants were asked about the information sources used when deciding to prescribe a new drug, interactions with sales representatives, views of representatives' value, and guidelines they had read on appropriate industry interactions. Results: Two hundred fifty-one completed questionnaires (49%) were returned. Seventy-six percent of participants see sales representatives' information as at least somewhat valuable. Twenty-nine percent use representatives often or almost always when deciding whether to prescribe a new drug; 44% use them sometimes. Physicians in private practice are more likely than those in university hospitals to interact with, value, and rely on representatives; community hospital physicians tend to fall in the middle. Gender and age are not associated with industry interaction. Dispensing samples is associated with increased reliance on representatives when making prescribing decisions, beyond what is predicted by a physician's own beliefs about the value of representatives' information. Reading guidelines on physician-industry interaction is not associated with less reliance on representatives after controlling for practice setting.  Conclusions: Physicians' interactions with industry and their familiarity with guidelines vary by practice setting, perhaps because of more restrictive policies in university settings, professional isolation of private practice, or differences in social norms. Prescribing samples may be associated with physicians' use of information from sales representatives more than is merited by the physicians' own beliefs about the value of pharmaceutical representatives.

Ross DS, Rasmussen SA, Cannon MJ, Anderson BA, Kilker K, Tumpey A, Schulkin J, & Jones JL.Obstetrician/Gynecologists' Knowledge, Attitudes, and Practices regarding Prevention of Infections in Pregnancy. J Womens Health. 2009;18(8):1187-1193.

Background: Maternal infection during pregnancy is a well-recognized cause of birth defects and developmental disabilities, as well as an important contributor to other adverse pregnancy outcomes. The objective of the present survey was to gain information about the knowledge, attitudes, and practices of obstetrician/gynecologists regarding prevention of infections during pregnancy.  Methods: A survey was mailed to 606 Collaborative Ambulatory Research Network (CARN) members of the American College of Obstetricians and Gynecologists (ACOG) (approximately 2% of membership). CARN members were sampled to demographically represent ACOG.  Results: Of the 606 eligible respondents, surveys were received from 305 (response rate: 50%). Most obstetrician/gynecologists knew that specific actions by pregnant women could reduce the risk of infection. Seventy-nine to eighty-eight percent reported counseling pregnant women about preventing infection from Toxoplasma gondii, hepatitis B virus, and influenza, 50%–68% about varicella-zoster virus, Listeria monocytogenes, and Parvovirus B19, and <50% about cytomegalovirus, Bordetella pertussis, and lymphocytic choriomeningitis virus. The majority reported time constraints were a barrier to counseling, although most reported educational materials would be helpful. Conclusions: Knowledge was accurate and preventive counseling was appropriate for some infections, but for others it could be improved. Further studies are needed to identify strategies to increase preventive counseling.

Leddy MA, Jones C, Morgan MA, Schulkin J. Eating disorders and obstetric-gynecologic care. J Womens Health (Larchmt). 2009;18(9):1395-1401.

Objective: Disordered eating can have consequences for gynecologic and obstetric patients and fetuses. Amenorrhea, infertility, hyperemesis gravidarum, and preterm birth have been linked to eating disorders (EDs). This study aimed to evaluate obstetrician-gynecologists' ED-related knowledge, attitudes, and practices. Methods: Questionnaires were sent to 968 Fellows of the American College of Obstetricians and Gynecologists between November 2007 and March 2008. Data were analyzed separately for generalists (provide obstetric and gynecologic care) and gynecologists only (treat only gynecologic patients). Results: A majority of obstetrician-gynecologists assess body weight, exercise, body mass index, and dieting habits. Less than half assess ED history, body image concerns, weight-related cosmetic surgery, binging, and purging. Over half (54%) of generalists believed ED assessment falls within their purview. Most (90.8%) generalists agreed or strongly agreed that EDs can negatively impact pregnancy outcome. A majority rated residency training in diagnosing (88.5%) and treating (96.2%) EDs as barely adequate or less. Most knew low birth weight (91%) and postpartum depression (90%) are associated with maternal EDs, though over a third was unsure about several consequences. Some gender differences emerged; females screen for more ED indicators and are more likely to view ED assessment as within their role. Conclusion: Despite the consequences of EDs and the fact that most physicians agree EDs can negatively impact pregnancy, only about half view ED assessment as their responsibility. Only some weight- and diet-related topics are assessed, and there are gaps in knowledge of ED consequences. Obstetrician-gynecologists are not confident in their training regarding EDs. Improvement in knowledge and altering obstetrician-gynecologists' view of their responsibilities may improve ED screening rates.

Anderson BL, Juliano LM, Schulkin J. Caffeine's implications for women's health and survey of obstetrician-gynecologists' caffeine knowledge and assessment practices. J Womens Health (Larchmt). 2009;18(9):1457-1466.

Objective: Caffeine has relevance for women's health and pregnancy, including significant associations with spontaneous abortion and low birth weight. According to scientific data, pregnant women and women of reproductive age should be advised to limit their caffeine consumption. This article reviews the implications of caffeine for women's psychological and physical health, and presents data on obstetrician-gynecologists' (ob-gyns) knowledge and practices pertaining to caffeine. Methods: Ob-gyns (N = 386) who are members of the American College of Obstetricians and Gynecologists' Collaborative Ambulatory Research Network responded to a 21-item survey about caffeine. Results: Although most knew that caffeine is passed through breast milk, only 24.8% were aware that caffeine metabolism significantly slows as pregnancy progresses. Many respondents were not aware of the caffeine content of commonly used products, such as espresso and Diet Coke, with 14.3% and 57.8% indicating amounts within an accurate range, respectively. Furthermore, ob-gyns did not take into account large differences in caffeine content across different caffeinated beverages with most recommending one to two servings of coffee or tea or soft drinks per day. There was substantial inconsistency in what was considered to be "high levels" of maternal caffeine consumption, with only 31.6% providing a response. When asked to indicate the risk that high levels of caffeine have on various pregnancy outcomes, responses were not consistent with scientific data. For example, respondents overestimated the relative risk of stillbirths and underestimated the relative risk of spontaneous abortion. There was great variability in assessment and advice practices pertaining to caffeine. More than half advise their pregnant patients to consume caffeine under certain circumstances, most commonly to alleviate headache and caffeine withdrawal. Conclusions: The data suggest that ob-gyns could benefit from information about caffeine and its relevance to their clinical practice. The development of clinical practice guidelines for caffeine may prove to be useful.

Morgan MA, Crall J, Goldenberg RL, Schulkin J. Oral health during pregnancy. J Matern Fetal Neonatal Med. 2009;22(9):733-739.

Objectives. To assess how obstetrician-gynecologists address oral health during pregnancy. Methods. Questionnaires were mailed to obstetrician-gynecologists in March 2008. Results. The response rate was 41%, with 351 respondents included in the final analysis. Most obstetrician-gynecologists agree that routine dental care during pregnancy is important (84%), periodontal disease can have adverse effects on pregnancy outcome (84%), and treating periodontal disease positively affects pregnancy outcome (66%). The majority seldom ask pregnant patients whether they have recently seen a dentist (73%), ask about current oral health (54%), or provide information about oral care (69%). Over a third (38%) do not advise patients to see a dentist for routine prophylaxis, 80% of these saying they had not previously thought about it. Most respondents (77%) reported having patients be declined dental services because of pregnancy. Over half (52%) indicated lack of insurance as a substantial barrier to oral care. Conclusion. Obstetrician-gynecologists recognize the importance of good oral health during pregnancy but largely do not address it. Improved training in the importance of oral health, recognizing oral health problems, and knowledge of procedure safety during pregnancy may make doctors more comfortable with assessing oral health and more likely to address it with patients.

Power ML, Cogswell ME, Schulkin J. US obstetrician-gynaecologist's prevention and management of obesity in pregnancy. J Obstet Gynaecol. 2009;29(5):373-377.

A survey regarding management of obesity in pregnancy was mailed to 787 practising members of the American College of Obstetricians and Gynecologists (ACOG); 433 responded of whom 353 practised obstetrics. Most (79.2%) had read ACOG Committee Opinion, 'Obesity in Pregnancy,' and rated it helpful (68.6%) or very helpful (17.2%). Most responding physicians (91.2%) use BMI to assess their patients weight status; fewer (63.4%) use pre-pregnancy BMI to modify their pregnancy weight gain recommendation. Having read the Committee Opinion and being a woman were independent factors associated with using pre-pregnancy BMI. Responding physicians that had read the Committee Opinion were more knowledgeable about obesity-related pregnancy complications; but even among those physicians, only 32.2% were aware that maternal obesity is a risk factor for fetal neural tube defects. The responding physicians appeared well-versed on appropriate practice for caesarean delivery for obese patients whether they had read the Committee Opinion or not.

Stumpf PG, Anderson BL, Lawrence H, Schulkin J. Obstetrician-gynecologists' opinions about patient safety: costs and liability remain problems; are mandated reports a solution? Womens Health Issues. 2009;19(1):8-13.

Background: To elucidate the patient safety practices of obstetrician-gynecologists (OB/GYNs), the perceived barriers to patient safety improvements in obstetrics and gynecology, and OB/GYN's beliefs about mandated reporting. Methods: A sample of 600 OB/GYNs was sent a survey from the American College of Obstetricians and Gynecologists about their beliefs and practice regarding patient safety. Results: The response rate was 53.2%. More than 92% of respondents said that patient safety is important in women's health care. The most important barriers to improving patient safety were cost of new technologies and concern about liability. Half agreed that mandatory reporting would improve patient safety. Physicians who practice in states with mandated error reporting were no more or less likely to think that these mandates improve patient safety than physicians who do not work in states with mandates. Physicians who practice in states with "I'm Sorry" laws more strongly disagreed that mandates improve patient safety than physicians who do not work in states with "I'm Sorry" laws. Discussion and Conclusions: It may be effective to aim at making patient safety activities more affordable to increase implementation. In addition, the effects of reporting and disclosure laws on physicians' concerns with liability should be examined more closely.

Power ML, Anderson BL, Schulkin J. Attitudes of obstetrician-gynecologists toward the evidence from the Women's Health Initiative hormone therapy trials remain generally skeptical. Menopause. 2009;16(3):500-508.

Objective: To examine the opinions of obstetrician-gynecologists regarding hormone therapy (HT) and the results from the Women's Health Initiative (WHI). Methods: Separate surveys were sent to two groups of practicing obstetrician-gynecologists: (1) respondents to a 2004-2005 survey (follow-up 1) and (2) members of the American College of Obstetricians and Gynecologists' Collaborative Ambulatory Research Network (follow-up 2 CARN). These studies complete a longitudinal study investigating obstetrician-gynecologists' opinions of the evidence from WHI. Results: Response rates were 64.5% and 58.8%, respectively. Responses from both surveys were generally consistent with the results from the 2004-2005 survey. A majority of physicians from both survey populations were skeptical of the combined HT results. Respondents were more likely to find the results of the unopposed estrogen trial convincing. Similar to the results from the 2004-2005 study, CARN physicians generally disagreed with the decision to end the WHI trials. Unlike the 2004-2005 study, there was no consistent effect of either age or year that residency was completed on physician opinions. Similar to the 2004-2005 study, physicians who considered alternative therapies as viable treatment options were more likely to report that they found the trial results convincing. The results from follow-up 2 CARN indicate that physicians in the south were most likely and physicians in the east were least likely to prescribe HT, suggesting that unmeasured sociocultural parameters might influence HT prescribing practice. Conclusions: Obstetrician-gynecologists remain generally skeptical of the WHI results, although less so of the estrogen-only trial. The early end to the trials may have contributed to their skepticism.

Coleman VH, Morgan MA, Carlson R, Hawks D, Schulkin J. Patient perceptions of obstetrician-gynecologists' practices related to HIV testing. Matern Child Health J. 2009;13(3):355-363.

Objectives: The objectives of this study were to (1) determine the percentage of obstetrician-gynecologists' patients who have been tested for HIV; (2) examine patient attitudes about HIV testing and patients' knowledge about their own risk status; (3) determine primary reasons patients decline an HIV test; and (4) learn patient recall of how their obstetrician-gynecologists approach the topic of HIV testing. Methods: Survey packets were mailed to each of 687 obstetrician-gynecologists who are members of the Collaborative Ambulatory Research Network (CARN) to distribute to their patients. Data are reported from 851 patient respondents (297 pregnant and 554 non-pregnant), and were analyzed utilizing independent samples t-tests, chi2 analysis, and linear regression. Results: Two-thirds of respondents (65%/n = 534) reported having been tested for HIV at some point, although the majority (72%) did not recall that their current obstetrician-gynecologist had recommended HIV testing. Among pregnant respondents specifically, 61% did not recall that their current obstetrician-gynecologist had recommended HIV testing, although 82% reported having had an HIV test at some point and 71% stated they had received their most recent HIV test results from their obstetrician-gynecologist during their current pregnancy. Age, race, and pregnancy status were linked to likelihood of patient recall of receiving an HIV testing recommendation from their obstetrician-gynecologist; with young, pregnant, Hispanic, and African-American patients most likely to recall a test recommendation. Perceived low risk was the primary reason given for declining an HIV test. Only 2% of respondents considered themselves high-risk for HIV despite almost half of the sample reporting having had unprotected sex at some point with more than one partner. Conclusions: Many patients did not recall that their obstetrician-gynecologist had ever recommended HIV testing, although the majority had been tested. Efforts should be made to increase communication between obstetrician-gynecologists and their patients related to HIV risk status and HIV testing.

Coleman VH, Lawrence H, & Schulkin, J. (2009).  Rising Cesarean Delivery Rates: The Impact of Cesarean Delivery on Maternal Request.  Obstetrical & Gynecological Survey, 64(2): 115-119.

Primary and repeat cesarean delivery rates have reached their highest levels both nationally and internationally, with 30.3% of live births in the United States being cesarean deliveries. Some cite the increase in cesarean delivery on maternal request (CDMR) as a contributing factor, although data have yet to confirm this. Concern about the rising number of cesareans performed, and the lack of clear knowledge about health outcomes for both mother and neonate as a result of this trend prompted the National Institute of Child Health and Human Development and the Office of Medical Applications of Research of the National Institutes of Health to convene a State-of-the-Science Conference on the topic of CDMR from March 27 to 29, 2006. Before this conference, a study was conducted by the American College of Obstetricians and Gynecologists to assess practice patterns and opinions related to CDMR among obstetrician-gynecologists. It was found that most obstetrician-gynecologists recognized an increased demand for CDMR in their practices. Conclusions from this study and the conference are reviewed along with more recent research on this topic.

Driscoll DA, Morgan MA, Schulkin J. Screening for Down syndrome: changing practice of obstetricians. Am J Obstet Gynecol. 2009;200(4):459.e1-459.e9.

Objective: We sought to assess the impact of American College of Obstetrician and Gynecologists (ACOG) guidelines on the practices and knowledge of obstetricians regarding screening for Down syndrome 1 year later. Study Design: A questionnaire on Down syndrome screening was mailed to 968 ACOG Fellows and Junior Fellows. Results: The response rate was 53%. The majority (95%) of respondents offer Down syndrome screening to all pregnant patients; 70% of general obstetricians offer the first-trimester screen and 86% the quad screen. Almost two-thirds (63%) of respondents are offering patients >/= 1 combination of first- and second-trimester screening tests. For women aged < 35 years, 70% offer amniocentesis selectively and 15% routinely. Chorionic villus sampling is offered less frequently. Respondents who more closely read the bulletin were more likely to say their practice had changed, answered more knowledge questions correctly, and felt more qualified to counsel patients. Most (85%) obstetricians personally counsel patients about Down syndrome risk and screening tests. The majority (94-95%) of respondents have access to adequate resources for screening within a 90-minute drive. Conclusion: Obstetricians have adopted a new paradigm for Down syndrome screening. First-trimester screening has been incorporated into prenatal care. Experience with these current screening tests will likely influence future guidelines and challenge the long-standing tradition of offering diagnostic testing based on maternal age. This study highlights the need for concise, unambiguous guidelines and a need to address unresolved issues in Down syndrome screening.

Goldstein LS, Chapin JL, Lara-Torre E, Schulkin J. The care of adolescents by obstetrician-gynecologists: a first look. J Pediatr Adolesc Gynecol. 2009;22(2):121-128.

Study Objective: To determine whether obstetrician-gynecologists who typically care for adolescent patients, what this care entails, and the adequacy of training opportunities in adolescent health care. Design: A questionnaire designed to elicit information regarding practice patterns of obstetrician-gynecologists mailed to the American College of Obstetricians and Gynecologists Collaborative Ambulatory Practice Network. Participants: Obstetrician-gynecologists whose patient populations included girls under the age of 18.  Main Outcome Measure: Items in the questionnaire were generated to determine what care obstetrician-gynecologists are providing to adolescents, whether this care meets practice guidelines of major medical organizations, and whether obstetrician-gynecologists are receiving adequate training to provide this care. Results: Obstetrician-gynecologists frequently care for adolescent patients, with 72.6% seeing adolescents either monthly or weekly. The most frequently cited service needs pertained to reproductive health. Obstetrician-gynecologists also provide primary care, with 55.2% currently providing immunizations to adolescent patients. Nearly all (96.5%) plan to provide HPV immunizations. Most (80% or more) considered their residency training in obstetrics-gynecology on reproductive health to be adequate, but many reported inadequate or no training on primary care. Conclusions: Obstetrician-gynecologists are an important part of the health care team caring for female adolescent patients. There is a lack of training during residency in obstetrics-gynecology in adolescent primary care issues. Increased training of obstetrician-gynecologists in all aspects of adolescent health care may increase the pool of health care providers who care for adolescents adequately. Collaborative efforts among all adolescent health care providers can improve access to quality health care for adolescents and the health of this population.

Henderson ZT, Power ML, Berghella V, Lackritz EM, Schulkin J. Attitudes and practices regarding use of progesterone to prevent preterm births. Am J Perinatol. 2009;26(7):529-536.

We sought to describe current attitudes and practices of obstetrician-gynecologists regarding use of progesterone and prevention of preterm birth. A self-administered survey was mailed to American College of Obstetricians and Gynecologists Fellows and Junior Fellows in Practice in March to May 2007. The survey consisted of 36 questions, including respondents' demographic characteristics, preterm birth risk factor knowledge and screening practices, and use of progesterone for the prevention of preterm birth. The response rate was 52% ( N = 345); most respondents were general obstetrician-gynecologists (89%). Many (74%) reported recommending or offering progesterone for prevention of preterm birth. Almost all (93%) reported use for the indication of previous spontaneous preterm birth. However, many also reported use for other indications such as dilated/effaced cervix (37%), short cervix on ultrasound (34%), and cerclage (26%). These results suggest that most obstetricians recommend or offer progesterone to prevent preterm birth for women with a previous spontaneous preterm birth and many also offer it for women with other high-risk obstetric conditions.

Leddy MA, Gonik B, Gall SA, Anderson BA, & Schulkin J. (2009).  Changes in immunization practices, knowledge and beliefs of Michigan obstetrician-gynecologists since 2000.  Michigan Journal of Public Health, 3(1), 20-32.

A majority of obstetrician-gynecologists view themselves as fulfilling a primary care role, and one important component of primary care is the administration of vaccines against diseases that have an impact on general health. Additionally, infections remain a leading cause of preventable morbidity in pregnant women and newborns. Thus, ob-gyns are in a unique position to provide immunizations to improve women’s health. A 2000 survey of obstetricians and gynecologists in Michigan found that a majority considered screening for vaccine-preventable diseases an important responsibility. However, only 10% routinely assessed whether patients had indications for all of the vaccines recommended for use in pregnant or recently delivered women. Moreover, one quarter of providers in this survey did not administer any vaccines to obstetric patients. Obstetrician-gynecologists identified costs of vaccination and a belief that vaccine administration was not the responsibility of obstetrician–gynecologists as the primary reasons for not offering vaccines. Our follow-up study investigated changes in the immunization knowledge, attitudes and practices of Michigan ob-gyns between 2000 and 2008. We found that in just less than one decade, there has been an increase in the proportion of Michigan obstetrician-gynecologists who view the administration of vaccines as within their professional role and part of their usual patient care activities. Additionally, more Michigan obstetrician-gynecologists are assessing patients’ needs for more vaccines. However, further gains are necessary; less than one in five respondents are assessing for all five vaccines in their gynecologic patients. Physicians were generally knowledgeable regarding vaccine recommendations. There has been some improvement in immunization-related knowledge over the past eight years; only 1.7% answered fewer than seven knowledge-based questions correctly, down from 5.5% in 2000. This study showed that a lack of available vaccines, and uncertainty regarding recommendations have become less of a problem, though financial concerns have increased. While there have been improvements in the assessment and administration of vaccinations it is important that more gains be made in viewing immunization as within their role, and part of their routine responsibilities.

Leddy MA, Anderson BL, Power ML, Gall S, Gonik B, Schulkin J. (2009). Changes in and current status of obstetrician-gynecologists' knowledge, attitudes, and practice regarding immunization. Obstet Gynecol Surv, 64(12):823-9.

Vaccines are important tools for disease prevention and, in obstetric patients, to prevent transmission to infants. Obstetrician-gynecologists are well situated to screen for immunization status of women of child-bearing age and to provide appropriate vaccinations. A series of research investigated obstetrician-gynecologists' beliefs, practices, and knowledge regarding immunization. Surveys were sent out in 2007 to Fellows of the American College of Obstetricians and Gynecologists. Most obstetrician-gynecologists viewed screening for vaccine-preventable diseases to be within their professional role, and a majority administers at least some vaccines. Over half agreed financial factors (eg, inadequate reimbursement, cost of storing vaccines) were barriers to vaccine administration. Other perceived barriers were a concern over safety of vaccinations during pregnancy and a view that administering vaccines was not part of their usual practice. They were also concerned about their level of training. A majority believed their immunization training was less than adequate, and believed their practice would benefit from continuing medical education courses. One study identified changes in Michigan obstetrician-gynecologists' attitudes, knowledge and practices since 2000. More Michigan ob-gyns are assessing vaccination needs, viewing this as part of their professional purview, and, in general, their knowledge of vaccine recommendations has improved. Concerns over the safety of vaccines in pregnancy as well as financial burdens of immunization have increased. Immunization is an important part of women's health care and has been, at least partially, incorporated into obstetrician-gynecologist practice. Financial burdens and physician concerns over training remain barriers to vaccine administration.

Power ML, Leddy MA, Anderson BL, Gall S, Gonik B, Schulkin J. Obstetrician-gynecologists’ practices and perceived knowledge regarding immunization. Am J Prev Med 2009;37:231-234.

Obstetrician-gynecologists are well situated to provide appropriate vaccinations to women of child-bearing age. This study investigated their immunization practices and knowledge, and opinions concerning potential barriers. Surveys were sent in 2007 to Collaborative Ambulatory Research Network (CARN) members, a representative sample of Fellows of the American College of Obstetricians and Gynecologists; 394 responded (51.2%). Data analysis was completed in 2008. Most responding obstetrician-gynecologists viewed screening for vaccine-preventable diseases to be within their professional role. A majority (78.7%) stock and administer at least some vaccines.  Among those who stock vaccines, 91.0% stock the HPV vaccine and 66.8% stock the influenza vaccine. All other vaccines were stocked by less than 30% of practices that stock vaccines. Over half agreed financial factors (e.g. inadequate reimbursement, cost of storing vaccines) were barriers to vaccine administration. Most  respondents were aware that the influenza vaccine (89.8%), hepatitis B (64.0%) and Tdap (58.6%) are safe to administer during pregnancy, and that MMR (97.5%)  and Varicella (92.9%) are not. Most (84.5%) were in concordance with recommendations that all pregnant women should receive the influenza vaccine. A majority believed their immunization training was less than adequate, and believed their practice would benefit from continuing medical education courses. Immunization is an important part of women’s health care and has been, at least partially, incorporated into obstetrician-gynecologist practice. Financial burdens and knowledge regarding vaccine recommendations remain barriers to vaccine administration. Additional training and professional information may benefit obstetric-gynecologic practice.