Research Department Publications 2018

Arora K., Castleberry N., Schulkin J. (2018). Variation in Waiting Period for Medicaid Postpartum Sterilizations: Results of a National Survey of Obstetricians-Gynecologists. American Journal of Obstetrics & Gynecology. 218(1): 140-141.

The Medicaid Title XIX sterilization forms were mandated in 1976 to protect vulnerable women from coercive sterilization. The forms require a 30 day waiting period between when the form is signed and when sterilization can occur but does allow for a shorter 72 hour interval prior to postpartum sterilization following premature delivery. Given the infrastructure of Medicaid, variation could potentially exist in defining the term, premature delivery, in a federally mandated but state-based form. Therefore, we sought to survey the practices of obstetricians-gynecologists surrounding the waiting period for postpartum sterilization in the Medicaid population. We hypothesized that there would not be variation in the definition of premature delivery, given the federal nature of the consent form.

Delgado, A., Stark L., Macri, C., Power, M., Schulkin, J. (2018). Provider and patient knowledge and views of office practices on weight gain and exercise during pregnancy. American Journal of Perinatology. 35(2): 201-208.

OBJECTIVES: The purpose of this survey study was to assess provider and patient knowledge and beliefs on gestational weight gain (GWG) and exercise during pregnancy and their views of suggested educational tools to increase practice efficacy.

METHODS: Providers and patients at GW MFA OB/GYN clinic were recruited for a voluntary survey. Descriptive statistics of responses were compared and chi square analysis was used to test for significant associations. 

RESULTS: A total of 461 patient and 36 provider questionnaires were analyzed. Most providers reported no standard protocol to counsel patients on GWG (83.3%), but thought determining a woman’s BMI was important (91.7%). Providers generally recommended GWG consistent with IOM guidelines for a “normal” BMI (82.9%), however, a majority (52.8%) recommended GWG below IOM recommendations for obese women. All providers reported counseling patients on GWG, but only 53.4% of patients reported discussing their personal GWG recommendation. About half of providers reported distributing educational materials for GWG (60.0%) and local resources for exercise (43.8%), however only 30.6% and 6.5% of patients reported receiving them, respectively. African American patients self-reported receiving the highest rates of counseling and educational materials, though a lower rate of recommendations to exercise. Patients generally perceived educational tools to be more useful than did providers. 

CONCLUSIONS: Our findings suggest a gap between patient and provider perceptions regarding counseling and provision of informational materials about GWG. Future research should study whether implementing various educational tools, especially those in exam and waiting rooms, might increase the efficacy of current practices.

Fialkow M., Snead C., Schulkin J. (2018). Benefits and barriers to teaching medical students in an ob-gyn clinic. Health Services Research & Managerial Epidemiology. 5:1-9.

INTRODUCTION: As the US health-care system has evolved over the past decade, access to obstetric care in rural communities has declined, and there has been a challenge in retaining obstetrics and gynecology (OB-GYN) providers to train the next generation of physicians. The current pilot study sought to identify the factors that influence faculty who train medical students within the field of OB-GYN with the hope of influencing recruitment and retention of providers for the future.

METHODS: Clinical OB-GYN faculty within the University of Washington School of Medicine regional medical education program were surveyed about practice patterns and beliefs regarding medical student training as part of a pilot study on provider recruitment and retention.

RESULTS: Fifty-seven eligible respondents completed the survey. Most (88.9%) reported their hospitals encourage student participation in patient care. Students in their practices participate in many aspects of patient care, including conducting exams (96.2%) and participating in the operating room (94.3%). The majority found the rewarding aspects of teaching medical students to be intellectual stimulation (90.9%), continuing the tradition of medical teaching (87.5%), and the intrinsic satisfaction of teaching (83.6%). Challenging aspects of teaching included reduced reimbursement (40%) and the student/workload (63.6%).

DISCUSSION: Medical student education continues to rely on a generation’s medical professionals to impart their knowledge to the next. We hope that with a better understanding of the benefits of participation and minimization of the challenges, we can perpetuate this tradition despite the uncertainty in our health-care system.

Jones K., Taouk L., Castleberry N., Carter M., Schulkin J. (2018). IPV Screening and Readiness to Respond to IPV in Ob-Gyn Settings: A Patient-Physician Study. Advances in Public Health. 2018: 1586987.

PURPOSE: Intimate partner violence (IPV) is a serious, preventable public health concern that largely affects women of reproductive age. Obstetrician-gynecologists (ob-gyns) have a unique opportunity to identify and support women experiencing IPV to improve women’s health. Considering recent efforts to increase IPV awareness and intervention, the present study aimed to provide a current evaluation of nationally representative samples to assess ob-gyn readiness to respond to IPV as well as patient IPV-related experiences. 

METHODS: 400 ob-gyns were randomly selected from American College of Obstetricians and Gynecologists’ (ACOG) Collaborative Ambulatory Research Network. Each physician was mailed one physician survey and 25 patient surveys. 

RESULTS: IPV training/education and IPV screening practices were associated with most measures of ob-gyn readiness to respond to IPV. Among respondents, 36.8% endorsed screening all patients at annual exams; however, 36.8% felt they did not have sufficient training to assist individuals in addressing IPV. Workplace encouragement of IPV response was associated with training, screening, detection, preparation/knowledge, response practices, and resources. Thirty-one percent of patients indicated their ob-gyn had asked about possible IPV experiences during their medical visit. 

CONCLUSION: Findings highlight specific gaps in ob-gyns’ IPV knowledge and response practices to be further addressed by IPV training.

Madsen A., Stark L., Has P., Emerson J., Schulkin J., Matteson K. (2018). Opioid Knowledge and Prescribing Practices Among Obstetricians-Gynecologists. Obstetrics & Gynecology. 131(1): 150–157.

OBJECTIVE: To describe obstetrician–gynecologists’ (ob-gyns) knowledge and prescribing practices regarding opioid analgesics.

METHODS: We conducted a cross-sectional survey of a national sample of American College of Obstetricians and Gynecologists Fellows and Junior Fellows who are part of the Collaborative Ambulatory Research Network. We used a sequential mixed-method approach. We collected data on opioid knowledge and typical prescribing practices, including number, type, and indication for prescriptions. We determined adherence to four recommended practices: 1) screening for dependence, 2) prescribing the smallest amount required, 3) tailoring prescriptions, and 4) counseling on proper disposal. We also explored variables associated with prescribing practices.

RESULTS: Sixty percent (179/300) of sampled members responded. Respondents reported prescribing a median of 26 (5–80) pills per patient across all indications combined. Ninety-eight percent prescribed opioids after surgery and a smaller proportion for nonsurgical indications: vaginal birth (22%), ovarian cysts (30%), endometriosis (24%), and chronic pelvic pain of unknown cause (18%). The number prescribed varied only by indication for the prescription. Nineteen percent reported adherence to three or more (of four) recommended practices. There was no significant difference in the median number of pills prescribed between those who reported adherence to at least one compared with those who did not adhere to any recommended practices (25 [interquartile range 25–30] vs 28 [interquartile range 20–30], P5.58). Regarding knowledge, 81% incorrectly identified the main source of misused opioids, which is through diversion from a friend or family member, and 44% did not know how to properly dispose of unused prescription opioids.

CONCLUSION: Obstetrician–gynecologists reported prescribing a median of 26 opioid pills across all indications combined. Amount prescribed varied widely by indication but not by reported adherence to recommended prescribing practices. This study highlights an urgent need for increased efforts to improve ob-gyns’ knowledge of opioid use, misuse, disposal, and best prescribing practices.

Taouk, L., Matteson, K., Stark, L., Schulkin, J. (2018). Prenatal Depression Screening and Antidepressant Prescription: Obstetrician-Gynecologists' Practices, Opinions, and Interpretation of Evidence. Archives of Women's Mental Health. 21(1): 85-91.

OBJECTIVES: Obstetrician-gynecologists (ob-gyns) are ideally positioned to detect symptoms of perinatal depression, however, little is known about how they screen for and respond to patient reports of depression, especially in the absence of high-quality safety data for antidepressant use during pregnancy. The purpose of the study was to evaluate ob-gyns’ beliefs and practices related to prenatal depression screening and antidepressant prescription during pregnancy.

METHODS: A survey on prenatal medication use was developed at [removed for blind review] and distributed to a sample of 1,000 Fellows. Of the 379 respondents, 288 provided care to pregnant patients and therefore, responded to a series of questions on prenatal depression management.

RESULTS: Most ob-gyns (87.8%) routinely screened patients for depression at least once during pregnancy. When symptoms of depression were reported, 52.1% ‘sometimes’ prescribed an antidepressant medication with 22.5% doing so ‘usually or always’. While 84.0% prescribed selective serotonin reuptake inhibitors (SSRIs) to pregnant patients, 31.9% prescribed non-SSRIs. Ob-gyns felt comfortable prescribing SSRIs (78.1%) and counseled patients: the benefits of treating depression pharmacologically outweigh the risks (83.0%) and the use of SSRIs during pregnancy is relatively safe (87.5%). Prescribing SSRIs was not significantly associated with interpretation of evidence on fetal and neonatal outcomes.

CONCLUSIONS: Our study suggests that despite the challenge of navigating recommendations based on contradictory and limited evidence, ob-gyns are aware of major recommendations and practice accordingly. As prenatal depression screening is increasingly implemented, it should be conducted with procedures in place to ensure appropriate diagnosis, treatment, and follow-up.

In Press

Urban, R., Taouk, L., Mendiratta, V., Peters, E., Schulkin, J. (2018, In Press.) Obstetrician/gynecologist practice patterns in the care of obese patients with endometrial hyperplasia and carcinoma. The Journal of Reproductive Medicine.

OBJECTIVE: This study was conducted to investigate obstetricians and gynecologists’ (ob-gyns’) counselling practices and perspectives pertaining to obesity in the context of a diagnosis of endometrial hyperplasia or carcinoma.

METHODS: A cross-sectional national survey study of ob-gyns was conducted and the results were analyzed with chi-square and t-tests

RESULTS: One-hundred and forty physicians responded to the survey for a response rate of 55.34%. Most respondents (45.2%) indicted that about half of their patients were overweight or obese. However, only 11.1% had received prior training in obesity management or counseling. Two thirds of respondents selected the diagnosing physician (36.5%) or a general ob-gyn (35.8%) as best suited to address weight reduction as a therapeutic strategy for patients with endometrial hyperplasia. Nearly all respondents (95.6%) agreed that other physicians, such as gynecologic oncologists or primary care physicians should also address it. Approximately half of respondents (47.1%) believed that at least one patient had left their practice because of an attempt to help them with their issue of being overweight or obese.

CONCLUSION: General ob-gyns discuss obesity and the associated health risks with patients having a new diagnosis of endometrial hyperplasia and cancer. In addition, they believe that discussing the risks of obesity should be a multidisciplinary effort. Further efforts to provide provider education on the risks and management of obesity are needed.

Leslie, M., Greene, J., Schulkin, J., Jelin, A. (2018, In Press). Umbilical Cord Clamping Practices of U.S. Obstetricians.  Journal of Neonatal-Perinatal Medicine.

Background: Delayed umbilical cord clamping is associated with significant benefits to preterm and term newborns and is recommended for all infants by the World Health Organization and the American College of Obstetricians and Gynecologists (ACOG). Little is known about the cord management practices of U.S. obstetricians. 

Objective: The objective of this study was to describe current cord clamping practices by U.S. obstetricians and investigate factors associated with delayed cord clamping. 

Study Design: A cross-sectional survey was sent to 500 members of the American College of Obstetricians and Gynecologists. Umbilical cord practices were assessed, and factors related to delaying cord clamping were examined using Chi-square tests and multivariate logistic regression models.  

Results: The overall response rate was 37% with 74% of those opening the email responding. Sixty-seven percent of respondents reported DCC by one minute or more after vaginal births at term. After preterm and near-term vaginal births, 73% and 79% said they waited at least 30 seconds before clamping. The factor most consistently and strongly related to delaying cord clamping in both bivariate and multivariate analyses was having the belief that the timing of clamping was important. Additional analysis revealed that believing the timing was important was positively associated with the physician’s institution having a written policy on the cord clamping.

Conclusion: This study shows that a majority of respondents report delaying cord clamping and that employing strategies to implement the full uptake of this practice could be valuable. Findings suggest that institutional policies may influence attitudes on cord clamping.

Rompalo A., Castleberry N., Widdice L., Schulkin J., Gaydos C. (2018, In Press). Patterns of Point of Care Test Use among Obstetricians and Gynecologists in the United States. Sexual Health. 

BACKGROUND: Point of care tests (POCTs) for reproductive health conditions have existed for decades. Newer POCTs for syphilis, HIV and trichomonas are currently available and easy-to-use. We surveyed practicing ob-gyns to determine POCT current use and perceived obstacles to use. 

METHODS: Between June and August 2016, 1000 members of the American College of OBGYN were randomly selected and invited to complete a Qualtrics survey: 600 were members of the Collaborative Ambulatory Research Network (CARN). Respondents who completed at least 60% of the survey were included in the analysis. 

RESULTS: 749 members had valid emails; 288 (39%) participated in and completed the survey. 70% were male, and average years practicing was 18. 30% reported diagnosing sexually transmitted infections (STIs) 1-2 times/week and 45% reported 1-2 times/month. POCTs used included pregnancy test (83%), urine dipstick (83%), wet mount test (79%) and the vagina pH test (54.8%). Few used Gram stain (5%) and stat RPRs (4%). Relatively newer FDA-approved POCTs were used less frequently with 25% reporting Affirm VPIII test use and only 10% using a rapid HIV test. The most common perceived barriers were the amount of reimbursement received for performing the test (61.9%) and the payment coverage from the patient (61.3%). 

CONCLUSIONS: U.S. ob-gyns rely on laboratory test results and traditional POCTs to diagnosis STDs. Future development and marketing of POCTs should consider not only ease and time of test performance but also cost of tests to the practice and the patient, as well as reimbursement.

Hostage, J., Arnetz, J., Cartin, A., Schulkin, J., Wax, J. (2018, In Press). Workplace Violence in Obstetrics and Gynecology – Results of a National Survey.  The Journal of Reproductive Medicine.

Objective: To evaluate the forms, frequency, and impact of workplace violence affecting obstetrician-gynecologists in a nationally representative sample.

Methods: Random sampling stratified by geographic district of the American College of Obstetricians and Gynecologists identified 5000 members who were asked to anonymously complete an on-line survey regarding experiences with workplace violence during the preceding 12 months. Members of the Armed Forces District or located outside of the United States were excluded. Data were analyzed using descriptive statistics and the Chi-square or Fisher exact test. Qualitative content analysis was conducted on free-text responses to the open-ended survey items using an inductive approach.

Results: Seven hundred sixty (15.2%) questionnaires were returned. Physical assault was reported by 35 (4.7%) respondents and verbal aggression was reported by 292 (39.9%) respondents. Females were significantly more likely to experience verbal aggression than males (OR 2.51; 95% CI 1.77-3.57). The most common reaction to experiencing workplace violence was anger (57.2%), followed by feeling anxious (38.2%), fearful (20.4%), or helpless (17.4%). 173 (57.3%) respondents described changes in attitude toward their work as a result of the violence, including enjoying work less (29.1%), considering changing practices (21.5%), less motivation (16.9%), and questioning one’s professional abilities or competence (13.6%). A negative impact on patient care was reported by 39.2% of those experiencing workplace violence. While 72% of respondents acknowledged the existence of a workplace violence reporting system, 69.9% never reported the incidents. A recurrent theme was physicians’ lack of knowledge regarding the legal ramifications of dealing with violent patients and family members.

Conclusions: A large proportion of obstetrician-gynecologists experience workplace violence that negatively impacts provider wellbeing and patient care. Most incidents are unreported, despite the existence of reporting systems. Education on violence prevention and clarity on legal and ethical ramifications of workplace violence is needed.

Contact:

Michael Power, PhD
mpower@acog.org

Carrie Snead, MA
csnead@acog.org

Neko Castleberry, MPP
ncastleberry@acog.org

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