Research Department Publications 2015

Atanasov P, Anderson B, Cain J, Schulkin J, Dana J. (2015). Comparing physicians personal prevention practices and their recommendations to patients. J Healthc Qual 37: 189-198.

BACKGROUND: Hypothetical choice studies suggest that physicians often take more risk for themselves than on their patient's behalf. 

OBJECTIVE: To examine if physicians recommend more screening tests than they personally undergo in the real-world context of breast cancer screening. 

DESIGN: Within-subjects survey. 

PARTICIPANTS: A national sample of female obstetricians and gynecologists (N = 135, response rate 54%) from the United States. In total, they provided breast care to approximately 2,800 patients per week. 

MEASURES: Personal usage history and patient recommendations regarding mammography screening and breast self-examination, a measure of defensive medicine practices. 

RESULTS: Across age groups, female physicians were more likely to recommend mammography screening than to have performed the procedure in the past 5 years (86% vs. 81%, p = .10). In respondents aged 40-49 this difference was significant (91% vs. 82%, p < .05), whereas no differences were detected for younger or older physicians. Among respondents in their 40s, 18% had undergone annual screenings in the past 5 years, compared to 48% of their colleagues above 50. Respondents were as likely to practice breast self-examination (98%) as to recommend it (93%), a pattern that was consistent across age groups. A logistic regression model of personal use of mammography significantly predicted recommending the procedure to patients (OR = 15.29, p = .001). Similarly, number of breast self-examinations performed over the past 2 years positively predicted patient recommendations of the procedure (OR = 1.31, p < .001). 

CONCLUSIONS: Obstetricians and gynecologists tended to recommend early mammography screening to their patients, though their personal practices indicated later start than their own recommendations and lower frequency of screening than peers in recent studies have recommended.

Davis, S., Anderson, B., Schulkin, S., Jones, K., Eng, J., Jones, J.(2015). Survey of obstetrician-gynecologists in the United States about toxoplasmosis: 2012 update.Archives of Gynecology and Obstetrics 291: 545-555.

PURPOSE: Toxoplasmosis, caused by the parasite Toxoplasma gondii, can have serious impacts on fetal development in the setting of acute maternal primary infection. The American College of Obstetricians and Gynecologists (ACOG) sought to determine current knowledge, practices, opinions, and educational preferences regarding T. gondii infection in pregnancy among ACOG members practicing prenatal care. 

METHODS: ACOG sent a survey to 1,056 members chosen by stratified random sampling from membership lists, including 370 participants and 686 non-participants in the Collaborative Ambulatory Research Network (CARN). Mailings were sent up to four times to nonresponders. 

RESULTS: Survey minimum response rates were 40.3 % (CARN) and 19.7 % (non-CARN); response rates adjusted for imputed non-eligibility were 59.7 % (CARN) and 22.6 % (non-CARN). Among providers, 80.2 % had diagnosed no acute maternal T. gondii infections in the past 5 years, 12.7 % correctly identified the screening role of the Toxoplasma avidity test, 42.6 % performed serologic T. gondii screening for at least some asymptomatic pregnant women, and 62.1 % of those who so did used appropriate approaches. Providers in the northeastern United States were 2.02 times more likely to routinely screen than those in the west (p = 0.025) and female providers were 1.48 times more likely than male providers (p = 0.047). The potential educational interventions considered useful by the most practitioners were updated ACOG guidelines on screening (81.4 %) and management (71.7 %) for acute T. gondii infection in pregnancy. 

CONCLUSIONS: ACOG members would benefit from educational efforts targeted at risk factor counseling and screening approaches.

Easter SR, Raglan GB, Little SE, Schulkin J, Robinso JN (2015). Perspectives on Global Health amongst Obstetrician Gynecologists: A National Survey. Women Heal Int 1(2):106.

OBJECTIVE: To characterize contemporary attitudes towards international healthcare of women amongst board-certified obstetrician-gynecologists. 

METHODS: A questionnaire was mailed to members of the American College of Obstetricians and Gynecologists. Respondents were stratified by interest in global health. 

RESULTS: Two-hundred-two (50.3%) of surveys were completed. 76.6% of respondents endorsed interest in global health while 25.1% had experience providing healthcare abroad. Knowledge of contributors to morbidity and mortality was poor with only 29% of questions answered correctly. Personal safety was the primary concern of respondents regarding time abroad (47.6%), and most identifying two weeks as an optimal period of time (44.6%) to spend abroad. The majority (60.8%) cited hosting of local physicians in the United States as the most valuable service to developing a nation’s health care provision. 

CONCLUSION: Despite high interest in global health, experience, knowledge, and willingness to spend time abroad were limited. Concerns surrounding personal safety amongst respondents dovetail with the belief that training local physicians in the US provides the most valuable service to international healthcare efforts. Though this approach alleviates security concerns, it brings its own challenges. Given that need is often highest in areas of unstable security; this concern represents a challenge to increasing involvement of Ob-Gyns in global women’s health.

Edmonds, B., McKenzie, F., Farrow, V., Raglan, G., Schulkin, J. (2015) A national survey of obstetricians’ attitudes toward and practice of periviable intervention. Journal of Perinatology 35: 338-343.

OBJECTIVE: Test the association between provider characteristics and antenatal interventions offered for periviable delivery. STUDY DESIGN: Six hundred surveys mailed to members of the College's Collaborative Ambulatory Research Network. Items queried physicians' practices regarding administering steroids, recommending cesarean (for breech) and offering induction (for ruptured membranes) at 23 weeks. 

RESULT: Three hundred and ten (52%) obstetricians (OBs) responded. Respondents reported institutional cutoffs of 23 weeks for resuscitation (34%) and 24 weeks for cesarean (35%), whereas personal preferences for cesarean were
25 weeks (44%). At 23 weeks, two-thirds ordered steroids, 43% recommended cesarean and 23% offered induction. In multivariable analyses, institutional cutoffs and providers' personal preferences predicted steroid administration (odds ratio, OR=4.37; 95% confidence interval, CI=1.73 to 11.00; OR=0.30, 95% CI=0.13 to 0.70); institutional cutoffs and the impression that cesarean decreases neurodevelopmental disability predicted recommending cesarean (OR=3.09, 95% CI=1.13 to 8.44; OR=6.41, 95% CI=2.06 to 19.91). For offering induction, practice location and religious service attendance approached, but did not meet, statistical significance (P=0.06 and P=0.05). 

CONCLUSION: OBs' willingness to intervene can impact periviable outcomes. These findings suggest that personal and institutional factors may influence obstetrical counseling and decision-making.

Edwards R, Tang Y, Raglan G, Szychowski J, Schulkin J, Schrag S.(2015) Survey of American Obstetricians regarding group B streptococcus: opinions and practice patterns. Am J Obstet Gynecol 213: 229.e1-7.

OBJECTIVE: The objective of the study was to evaluate attitudes and practice patterns of obstetricians related to screening for group B streptococcal colonization and providing intrapartum antibiotic prophylaxis against early-onset neonatal infections with group B streptococcus. 

STUDY DESIGN: We mailed a survey to 546 members of the American College of Obstetricians and Gynecologists, including members of the Collaborative Ambulatory Research Network and non-Collaborative Ambulatory Research Network members. Stratified random selection was used to generate samples from both of these groups. 

RESULTS: The survey response rate was 60% for Collaborative Ambulatory Research Network members and 42% for non-Collaborative Ambulatory Research Network members. Of the 206 respondents who reported providing prenatal care, 97% collect screening samples at 35-37 weeks' gestational age. Anatomic sites used to collect samples were more variable: 62% include lower vagina and rectum, 26% include lower vagina and perianal skin but not rectum, and 5% include neither the perianal skin nor the rectum. First-line agents for intrapartum antibiotic prophylaxis were penicillin (71%), ampicillin (27%), and cefazolin (2%). For patients reporting a nonanaphylactic penicillin allergy, drugs used for intrapartum antibiotic prophylaxis were more varied: cefazolin (51%), clindamycin (36%), vancomycin (8%), and erythromycin (5%). For patients undergoing a labor induction starting with a cervical ripening agent, less than 40% typically give the first dose of intrapartum antibiotic prophylaxis before or at the time of cervical ripening agent administration, and 15% wait until the patient reaches the active phase of labor. 

CONCLUSION: Gaps in knowledge and reported practice related to the prevention of early-onset neonatal group B streptococcus infections were similar to gaps in implementation of guidelines demonstrated in past studies. New approaches to improve implementation are warranted

Jelin A, Anderson B, Wilkins-Haug L, Schulkin J. (2015, Epub Ahead of Print)Obstetrician and gynecologists’ population-based screening practices. J Matern Fetal Neonatal Med.

BACKGROUND: The ability to obtain genetic information can now be accomplished in far greater detail, and more quickly than in the past. It is important to understand obstetrician-gynecologists' (ob-gyns) screening practices as these changes occur. 

METHODS: Cross-sectional survey was performed by mailing paper surveys to Fellows of the American College of Obstetricians and Gynecologists and a subset of Fellows who belong to the Collaborative Ambulatory Research Network (CARN). 

RESULTS: Response rates were 57% for the CARN network. Almost all responders (92%) offer population-based genetic screening in the prenatal period and almost all (93%) conduct counseling prior to the provision of genetic testing. Almost all (92%) counsel patients when the result is positive, with 46% being the primary counselor and 55% calling the patient themselves. When results are negative, 73% counsel with 58% indicating they are the primary counselor and 17% call patients themselves. A total of 72% have received continuing medical education (CME) on genetics within 5 years, with 79% receiving CME at conferences and 21% receiving CME online. 

CONCLUSION: Ob-gyns have a large role in providing patients new genetic screening technologies. This role requires a significant knowledge base, some of which can be obtained by online modules; however, our study suggests online education is underutilized as a means for CME on genetic screening among ob-gyns.

Jones K, Power M, Queenan J, Schulkin J. Racial and ethnic disparities in breastfeeding. Breastfeed Med; 2015: 10: 186-196.

This article's aim is to review the literature on racial and ethnic disparities in breastfeeding rates and practices, address barriers to breastfeeding among minority women, conduct a systematic review of breastfeeding interventions, and provide obstetrician-gynecologists with recommendations on how they can help increase rates among minority women. In order to do so, the literature of racial and ethnic disparities in breastfeeding rates and barriers among minority women was reviewed, and a systematic review of breastfeeding interventions among minority women on PubMed and MEDLINE was conducted. Racial and ethnic minority women continue to have lower breastfeeding rates than white women and are not close to meeting the Healthy People 2020 goals. Minority women report many barriers to breastfeeding. Major efforts are still needed to improve breastfeeding initiation and duration rates among minority women in the United States. Obstetrician-gynecologists have a unique opportunity to promote and support breastfeeding through their clinical practices and public policy, and their efforts can have a meaningful impact on the future health of the mother and child.

Jones, K., Raglan, G, Lannon, S., and Schulkin, J. (2015). Obstetrician-Gynecologists’ knowledge of health barriers and disparities among American Indian/Alaska Native women in Washington State. Journal of Health Disparities Research and Practice 8.

BACKGROUND: Pregnant and non-pregnant American Indian/Alaska Native (AI/AN) women have long suffered from poorer physical and mental health status than other races/ethnicities. Obstetrician-gynecologists (ob-gyns) play a significant role in well-woman care and are often the first and most frequent point of medical contact for women, Minority and low-income women are more likely to utilize their ob-gyn as a primary care provider. 

OBJECTIVE: To assess obstetrician-gynecologists knowledge, beliefs, and practices of racial and ethnic disparities of physical and mental health concerns among pregnant and non-pregnant AI/AN women. To determine barriers to providing adequate health care to AI/AN women and to identify resources to improve the quality of health care services offered to AI/AN patients.

Jones, K., Carter, M., and Schulkin, J. (2015). Racial and ethnic disparities in cardiovascular disease: An assessment of obstetrician-gynecologists’ knowledge, attitudes, and practice patterns. Journal of Ethnic and Racial Health Disparities, 2, 256-266. 

BACKGROUND: African American and Hispanic women are disproportionately affected by cardiovascular disease (CVD) and its many risk factors. Obstetrician–gynecologists (OB/GYNs) play an integral role in well-woman care and have a unique opportunity to provide CVD counseling and screening to these at-risk and underserved groups. 

OBJECTIVE: To assess whether OB/GYN race/ethnicity and OB/GYN practices with increasing minority patient populations predicted differences in OB/GYNs’ knowledge, attitudes, and practice patterns relevant to racial/ethnic disparities in CVD. This study also sought to determine provider and patient-related barriers to CVD care. 

METHOD: A questionnaire on CVD was mailed to 273 members of The American College of Obstetricians and Gynecologists in March–July 2013. 

RESULTS: African American and Hispanic OB/GYNs and OB/GYN practices with increasing minority patient populations were more knowledgeable of CVD disparities. These OB/GYNs reported greater concern for minority women’s CVD risk relative to White OB/GYNs. Overall, OB/GYNs appear less knowledgeable and concerned with Hispanics’ increased CVD risk relative to African Americans’. The most commonly reported provider and patient-related barriers to CVD care were time constraints, patient nonadherence to treatment recommendations, and inadequate training. 

CONCLUSION: It is likely that minority OB/GYNs and those with practices with increasing minority patient populations have greater exposure to women at risk for CVD. Dissemination of educational information regarding Hispanic women’s CVD risk profile may improve OB/GYN knowledge, counseling, and screening. Increased training in CVD and multicultural competency during medical school and residency should help OB/GYNs overcome what they report as primary barriers to CVD care.


Leddy M, Anderson B, Schulkin J. (2015). Obstetrician-gynecologists' Practices, Statistical Literacy, and Risk Communication with Regard to Sexually Transmitted Infections. Curr HIV Res 13: 391-8.

In order to best care for women, obstetrician-gynecologists (ob-gyns) must be able to diagnose and treat sexually transmitted infections (STIs), as well as effectively communicate risks regarding STIs. This article provides a narrative review of studies primarily conducted by the Research Department at the American College of Obstetricians and Gynecologists, about missed opportunities for STI risk communication. Missed opportunities include the omission or partial completion of STI risk assessment and counseling, failure to offer screening or testing, lack of follow-up on STI testing/vaccination refusals, and a failure to comply with existing guidelines. We also discuss knowledge level, time constraints, and gaps in statistical literacy as barriers to STI communication. The aim of this article is to highlight common barriers to risk communication, discuss their potential impact, and suggest means by which these obstacles can be addressed. Future directions for training, education, and research are discussed.

Levine, L., Schulkin, J., Mercer, B., O’Keefe, D., Berghella, V., Garite, T. (2015, Epub Ahead of Print). Role of Hospitalist and Maternal Fetal Medicine Physician in Obstetric Inpatient Care. American Journal of Perinatology.

OBJECTIVE: The objective of this study was to evaluate the role of hospitalists and Maternal Fetal Medicine (MFM) subspecialists in obstetrical inpatient care. 

STUDY DESIGN: This electronic survey study was offered to members of the American College of Obstetricians and Gynecologists (ACOG; n=1039) and the Society for Maternal Fetal Medicine (SMFM; n=1,813). 

RESULTS: Overall, 607 (21%) respondents completed the survey. Overall, 35$ reported that hospitalists provided care in at least one of their hospitals. Compared with ACOG respondents, a higher frequency of SMFM respondents reported comfort with hospitalists providing care for all women on labor and delivery (74.4 vs. 43.5%, p=0.005) and women with complex issues (56.4 vs. 43.5%, p=0.004). The majority of ACOG respondents somewhat/completely agreed that hospitalists were associated with decreased adverse events (69%) and improved safety/safety culture (70%). Overall, 35% of ACOG respondents have MFM consultation available with 53% having inpatient coverage. Of these, 85% were satisfied with MFM availability. 

CONCLUSION: Over one-third of respondents work in units staffed with hospitalists and more than half have inpatient MFM coverage. It is important to evaluate if and how hospitalists can improve maternal and perinatal outcomes, and types of hospitals that are best served by them.

Micks, E., Raglan, R., Schulkin, J. (2015). Bridging progestogens in pregnancy and pregnancy prevention. Endocrine Connections 4(4): R81-R92

Steroid hormones have been in use for over a half a century as contraceptive 34 agents, and only now are researchers elucidating the biochemical mechanisms of action 35 and non-target effects. Progesterone and synthetic progestins, critical for women’s health 36 in the U.S. and internationally, appear to have important effects on immune functioning 37 and other diverse systems. Apart from the contraceptive world is a separate field that is 38 devoted to understanding progesterone in other contexts. Based on research following a 39 development timeline parallel to hormonal contraception, progesterone and 17- 40 hydroxyprogesterone caproate are now administered to prevent preterm birth in high-risk 41 pregnant women. Preterm birth researchers are similarly working to determine the precise 42 biochemical actions and immunological effects of progesterone. Progesterone research in 43 both areas could benefit from increased collaboration and bringing these two bodies of 44 literature together. Progesterone, through actions on various hormone receptors, has 45 lifelong importance in different organ systems and researchers have much to learn about 46 this molecule from the combination of existing literatures, and from future studies that 47 build on this combined knowledge base.

Murtough, K.L., M.L. Power, J. Schulkin. (2015). Knowledge, attitudes and practices of obstetrician-gynecologists regarding influenza prevention and treatment following the 2009 H1N1 pandemic. Journal of Women’s Health.

Pregnant women are at increased risk for complications associated with influenza. Influenza vaccination during pregnancy helps protect both pregnant women and infants less than 6 months of age from contracting the flu. This study investigated influenza prevention and treatment practices of ob-gyns during the influenza season immediately following the 2009-2010 H1N1 season.

Raglan, G., Lawrence, H., and Schulkin, J. (2015). Ethical considerations of screening for mental health disorders during periodic well-woman exams. Psychosomatic Gynecology and Obstetrics 2: 1-8.

Mental health concerns, particularly depression and anxiety, are common among women of all ages. Because obstetrician/gynecologists (ob/gyns) often serve as a primary source of care for women, they are in a unique position to detect and target mental health symptoms early. In this context, we define ethics as the balance between one's competency in practice, and the need to treat patients with conditions outside of that competency. This paper discusses the ethical challenges that ob/gyns may face in identifying and treating mental health conditions due to lack of expertise, training, and experience. We also focus on the ethical considerations that favor interventions on the part of ob/gyns, and how improved training could help to resolve this ethical dilemma. In addition, the expansion of collaborative care networks may help to build continuity of care.

Raglan, G., Margolis, B., Paulus, R., Schulkin, J. (2015). Obstetrician/gynecologists' experiences with electronic health record systems: a narrative study. J Reprod Med 60: 95-102.

OBJECTIVE: To explore the experiences of obstetrician/gynecologists (ob/gyns) with regard to the use of electronic health record (EHR) systems in practice. 

STUDY DESIGN: Surveys were mailed to 1,200 ob/gyns, with an overall response rate of 57.2%, 402 of whom currently use an EHR system. The survey included questions about the physicians' use of EHR systems as well as what features they found most or least helpful. In addition, a focus group of 6 practicing ob/gyns at a university-based hospital was conducted in which they were encouraged to give free responses about their experiences working with EHR systems. Responses from surveys and the focus group were analyzed for frequency by the investigators. 

RESULTS: The majority of ob/gyns who used an EHR reported being satisfied with that system (61.4%). The most commonly reported impediments to EHR use were time needed, ineffective templates, note quality, interference with patient interactions, and expense. The most commonly cited positives were electronic medication prescription (e-scribing) capabilities, efficiency, and ease of access to notes, including legibility. 

CONCLUSION: In spite of increased adoption of EHR systems, more work is needed to improve ob/gyn satisfaction with EHR systems

Rayburn, W., Raglan, G., Herman, C., Schulkin, J. (2015, In Press). A Survey of Obstetrcian-Gynecologists Regarding their Care of Women 65 Years or Older. J Geriatr Med Gerontol 1:2-6.

OBJECTIVE: To survey a representative group of obstetrician-gynecologists (ob-gyns) about the frequency of care provided to women 65 years or older and the nature of health concerns in this high-need population.

DESIGN: Descriptive survey

PARTICIPANTS: Fellows and Junior Fellows of the American College of Obstetricians and Gynecologists (ACOG) in active practice.

MEASUREMENTS: A survey developed and tested by ACOG was mailed to 1,000 members, with an overall response rate of 42.7%. The survey included questions about physician demographics, delivery of care of women 65 or older, and health needs of their patients. Responses were compared between those who did or did not provide care for women 65 or older.

RESULTS: Of the 427 responders, 86.4% reported that they cared for older patients. A higher proportion of female ob-gyns cared for older patients than male physicians. Approximately half (54.8%) of all physicians surveyed reported adequate or comprehensive training in the overall treatment of older patients, and the majority expressed adequate or comprehensive training in counseling or treatment of issues relating to obesity, sexuality, fitness and nutrition, cardiovascular health, bone health, breast disorders, osteoporosis, and urinary conditions. Few saw older women alone, especially for conditions involving other systems including mental disorders.

CONCLUSIONS: Most obstetrician-gynecologists are engaged in the care of women 65 years and older, especially for preventive care, disease screening and early detection, and urogenital conditions. Most felt comfortable in the context of collaborative and coordinated care of older women with major medical or mental health concerns.

Tong, V.T, England, L.J, Malarcher, A., Mahoney, J., Anderson, B., Schulkin, J. (2015).Clinicians' awareness of the Affordable Care Act mandate to provide comprehensive tobacco cessation treatment for pregnant women covered by Medicaid. Prev Med Rep 2:686-688

The Affordable Care Act (ACA) requires states to provide tobacco-cessation services without cost-sharing for pregnant traditional Medicaid-beneficiaries effective October 2010. It is unknown the extent to which obstetricians–gynecologists are aware of the Medicaid tobacco-cessation benefit. We sought to examine the awareness of the Medicaid tobacco-cessation benefit in a national sample of obstetricians–gynecologists and assessed whether reimbursement would influence their tobacco cessation practice. In 2012, a survey was administered to a national stratified-random sample of obstetricians–gynecologists (n = 252) regarding awareness of the Medicaid tobacco-cessation benefit. Results were stratified by the percentage of pregnant Medicaid patients. Chi-squared tests (p < 0.05) were used to assess significant associations. Analyses were conducted in 2014. Eighty-three percent of respondents were unaware of the benefit. Lack of awareness increased as the percentage of pregnant Medicaid patients in their practices decreased (range = 71.9%–96.8%; P = 0.02). One-third (36.1%) of respondents serving pregnant Medicaid patients reported that reimbursement would influence them to increase their cessation services. Four out of five obstetricians–gynecologists surveyed in 2012 were unaware of the ACA provision that required states to provide tobacco cessation coverage for pregnant traditional Medicaid beneficiaries as of October 2010. Broad promotion of the Medicaid tobacco-cessation benefit could reduce treatment barriers.

Wright, J., Raglan, G., Schulkin, J., Fialkow, M. (2015). Attitudes and Beliefs Regarding the Utility of Robotically Assisted Gynecologic Surgery Among Practicing Gynecologists. Journal of Healthcare Quality.

While use of robotic-assisted surgery has increased rapidly, little is known about the attitudes and beliefs of practicing gynecologists regarding the utility of the technology. We surveyed a large sample of gynecologists to examine their attitudes and beliefs about the benefits, utility, and factors driving use of robotic-assisted gynecologic surgery. A 51-item survey was mailed to 600 fellows or junior fellows of the American College of Obstetricians and Gynecologists. The survey included questions on use of robotic surgery, decision-making, and beliefs regarding the technology. Responses were stratified based on whether the respondent used robotic surgery or not. A total of 310 responses were received including 27.8% who used robotic surgery in their practices. Hysterectomy was the most commonly performed procedure. Opinions about the use and effectiveness of robotic procedures varied based on whether an individual was a robot user. Eighty-two percentage of robot users and 21% of nonrobot users believed robotic surgery provided benefits over laparoscopic (p < .0001). Among both groups, the ability to increase access to minimally invasive surgery and marketing were believed to be the greatest drivers of use of robotic surgery. Attitudes and beliefs about the effectiveness of robotic gynecologic surgery are highly variable among clinicians.


Michael Power, PhD

Carrie Snead, MA


American College of Obstetricians and Gynecologists
409 12th Street SW, Washington, DC  20024-2188