Collaborative Ambulatory Research Network Research Articles

Vaccination and perinatal infection prevention practices among obstetrician–gynecologists

Objective To assist efforts to improve adult vaccination coverage by characterizing vaccination and infectious disease screening practices of obstetrician–gynecologists. Methods A written survey of demographics, attitudes, and practices was mailed to 1063 American College of Obstetricians and Gynecologists Fellows, including the Collaborative Ambulatory Research Network ( n = 413) and 650 randomly sampled Fellows. Results Seventy-four percent of Collaborative Ambulatory Research Network members and 44% of nonmembers responded. A majority (Collaborative Ambulatory Research Network members: 60%; nonmembers: 49%) considered themselves primary care providers. Fewer than 60% routinely obtained patient vaccination or infection histories. Most screened prenatal patients for hepatitis B surface antigen (89%) and rubella immunoglobulin G antibody (85%). Sixty-four percent worked in practices that offered at least one vaccine; the most common were rubella (52%) and influenza (50%). Ten percent worked in practices that offered all major vaccines recommended for pregnant or postpartum women. Despite recommendations to provide influenza vaccine to pregnant women during influenza season, only 44% did so; among those who did not, 14% reported a belief that pregnant women do not need influenza vaccine. Provision of vaccine was associated with working in a multispecialty practice (adjusted odds ratio [OR] 2.6, 95% confidence interval [CI] 1.6, 4.1) and identifying as a primary care provider (adjusted OR 1.9; 95% CI 1.3, 2.7). The most common reasons for not offering vaccines were cost (44%) and a belief that vaccines should be provided elsewhere (41%). Conclusion The high proportion of obstetrician–gynecologists who do not offer vaccines or screen for vaccine and infection histories suggests missed opportunities for prevention of maternal and neonatal infections.

Neonatal Encephalopathy and Cerebral Palsy: A Knowledge Survey of Fellows of The American College of Obstetricians and Gynecologists

OBJECTIVE: To assess practicing obstetricians' knowledge of the etiology and pathophysiology of neonatal encephalopathy and its relationship to cerebral palsy. METHODS: A questionnaire designed to test both knowledge and practice patterns was mailed to 413 members of the Collaborative Ambulatory Research Network of The American College of Obstetricians and Gynecologists (ACOG), as well as 600 randomly selected non-Network ACOG Fellows. The questionnaire was composed of 15 knowledge questions and three clinical scenarios containing seven knowledge questions. Six of the questions directly assessed knowledge of cerebral palsy. RESULTS: Of those who returned the questionnaire, 351 practiced obstetrics and were included in the statistical analyses. For the majority of questions, “Don't know” was the most frequent response. The next most frequent response for 8/13 questions was the correct answer. Performance was strongest as regarded actual clinical practice and relatively weak regarding the antecedents of neonatal encephalopathy and cerebral palsy. The physicians' actual knowledge scores showed a significant correlation with their self-assessments of knowledge (r= .41,P< .001). The majority of physicians rated their training on this topic in medical school, residency, and through continuing medical education as marginal or inadequate. CONCLUSION: The results of this survey identified large knowledge gaps in this area, suggesting a need to develop educational projects to address these deficits by both professional organizations and individual teachers. (Obstet Gynecol 2003;101:11-7. © 2003 by The American College of Obstetricians and Gynecologists.)

Neonatal encephalopathy and cerebral palsy: a knowledge survey of Fellows of The American College of Obstetricians and Gynecologists

OBJECTIVE: To assess practicing obstetricians’ knowledge of the etiology and pathophysiology of neonatal encephalopathy and its relationship to cerebral palsy. METHODS: A questionnaire designed to test both knowledge and practice patterns was mailed to 413 members of the Collaborative Ambulatory Research Network of The American College of Obstetricians and Gynecologists (ACOG), as well as 600 randomly selected non-Network ACOG Fellows. The questionnaire was composed of 15 knowledge questions and three clinical scenarios containing seven knowledge questions. Six of the questions directly assessed knowledge of cerebral palsy. RESULTS: Of those who returned the questionnaire, 351 practiced obstetrics and were included in the statistical analyses. For the majority of questions, “Don’t know” was the most frequent response. The next most frequent response for 8/13 questions was the correct answer. Performance was strongest as regarded actual clinical practice and relatively weak regarding the antecedents of neonatal encephalopathy and cerebral palsy. The physicians’ actual knowledge scores showed a significant correlation with their self-assessments of knowledge ( r = .41, P < .001). The majority of physicians rated their training on this topic in medical school, residency, and through continuing medical education as marginal or inadequate. CONCLUSION: The results of this survey identified large knowledge gaps in this area, suggesting a need to develop educational projects to address these deficits by both professional organizations and individual teachers.

Knowledge and clinical practice regarding calcium nutrition among obstetrician-gynecologists

Objective: To survey the knowledge of and attitude toward nutrition among practicing obstetrician-gynecologists, using calcium as a specific example. Methods: Our survey on calcium nutrition consisted of 29 questions divided into four categories: demographic information, professional interest and clinical practice, knowledge and opinions, and education. We mailed this survey to the 244 ACOG Fellows who are members of the Collaborative Ambulatory Research Network and to a random sample of 756 Fellows who are not members of the Collaborative Ambulatory Research Network. Results: Most (75.4%) respondents considered making dietary recommendations an important part of their practice. Interest in nutrition was correlated significantly with its perceived importance in clinical practice and was associated with a greater self-reported likelihood of making dietary recommendations to patients and referring patients to nutritional counseling. Nutrition was of greater importance to women and to older respondents. Women were more likely to make dietary recommendations to patients. Men were more likely to recommend nonfoods and higher fat foods as sources of dietary calcium. The daily calcium intake that obstetrician-gynecologists recommended for different types of patients varied widely but did not differ between male and female respondents. The responses to the knowledge questions concerning calcium metabolism were predominantly “don't know.” Conclusions: Although specific knowledge of calcium metabolism and regulation was incomplete, obstetrician-gynecologists generally recognized the importance of nutrition in their clinical practice. Being older and female independently increased the perceived importance of nutrition.

Practice trends in outpatient obstetrics and gynecology: findings of the Collaborative Ambulatory Research Network, 1995--2000.

Historically, obstetrics and gynecology has been a medical/surgical specialty focusing on women's health and reproductive concerns during the childbearing years. Newer responsibilities-for example, in primary care, gerontology, and genetics-require Ob-Gyns to draw upon a base of medical knowledge that traditionally was not considered germane to their practices. Ob-Gyns are increasingly providing more primary care services to their patients; consequently, the field has expanded considerably. The Collaborative Ambulatory Research Network (CARN) was created in 1990 as a vehicle for investigating issues pertinent to women's health and to the practice of obstetrics and gynecology in the outpatient setting. This article summarizes the findings of CARN studies from 1995 to 2000, covering a range of topics related to women's health across the life cycle, including, but not limited to perinatal care. Topics include nutrition, infectious disease, hormone replacement therapy, psychosocial issues, and genetic testing in obstetric and gynecologic practice. Each study produced a picture of current practice patterns and knowledge of the physicians surveyed. Findings on knowledge, attitudes, and practices varied widely. Overall, Ob-Gyns were knowledgeable and consistent in more traditional areas of practice. Conversely, inconsistencies were observed in newer areas. Obstetricians & Gynecologists, Family Physicians After completion of this article, the reader will be able to define what the Collaborative Ambulatory Research Network (CARN) involves, describe how CARN obtains its data, and summarize some of the findings of CARN from the years 1995 to 2000.

Group B streptococcal disease prevention practices of obstetrician-gynecologists

Objective: To describe group B streptococcal (GBS) disease prevention practices of obstetrician-gynecologists. Methods: We surveyed 1019 ACOG Fellows—the 419 members of the Collaborative Ambulatory Research Network (CARN) and 600 randomly selected non-CARN Fellows. Results: There were 601 eligible respondents. More than 95% in both the CARN and the non-CARN groups reported adopting one of three GBS prevention strategies. The most commonly reported strategy was a combination approach not described in the consensus guidelines. The second most common strategy was the screening-based strategy; the risk-based strategy was third. Most respondents provided GBS information to all prenatal patients, but those using a risk-based strategy and those in solo practice were less likely to do so. Less than 60% in each group used penicillin as their first choice for GBS prophylaxis. More than 20% in each group who routinely screened for GBS did not collect both vaginal and rectal cultures. Respondents rated ACOG publications as the most important influence on their GBS prevention approach. Conclusion: Almost all ACOG Fellows have adopted a GBS prevention strategy. The importance of providing GBS prevention information to all patients, use of penicillin, and collection of both vaginal and rectal cultures should be reinforced.

Effects of Perceptions and Mentorship on Pursuing a Career in Academic Medicine in Obstetrics and Gynecology

To understand the perceptions of residents and Fellows in obstetrics and gynecology about the impacts of race or ethnicity, gender, and mentorship experiences on pursuing careers in academic medicine. Two surveys were administered: one to a sample of 2,000 Fellows of the American College of Obstetricians and Gynecologists, and one to the 4,814 obstetrics and gynecology residents taking the 1998 in-training examination. The questionnaires asked about demographics, perceptions about careers in academic medicine, and residents' experiences with mentorship. Response rates were 96.8% for residents and 40.6% for FELLOWS: Of the residents, 26.1% indicated they would not consider a career in academic medicine. First-year women residents were more inclined to pursue careers in academic medicine than were first-year men (p =.042), but their interest declined during residency. Women residents (43%)-especially minorities-felt that men were mentored and recruited more for faculty positions, while men (38%) felt that women were mentored and recruited more. Fellows' reports of recruitment did not differ by gender. Most white residents did not perceive racial or ethnic bias in mentoring or recruiting, while most non-white residents did. Almost one third of non-white women residents felt that supervisors were more likely to condescend to women and minority individuals. It is likely that neither men nor women residents in obstetrics and gynecology receive adequate mentorship for careers in academic medicine. Perceptions of bias are a serious barrier to developing racial, ethnic, and gender diversity in leadership positions.

A survey on the management of nausea and vomiting in pregnancy by obstetrician/gynecologists

Our objective was to survey obstetrician/gynecologists concerning their management of nausea and vomiting in pregnancy. We mailed a survey on nutrition during pregnancy to the 230 ACOG Fellows who are members of the Collaborative Ambulatory Research Network and to a control sample of 800 non-Network Fellows. Results presented here are for the questions concerning prevalence and management of pregnancy-induced nausea. A total of 488 surveys (47.4% response rate) were analyzed. Respondents reported that on average, 51.4% of patients complain of nausea during pregnancy, and 9.2% complain of severe or prolonged nausea with vomiting. Respondents reported that on average, 2.4% of patients require hospitalization because of hyperemesis gravidarum. Treatments recommended by a majority of respondents for moderate nausea were eating frequent small meals (95.5%), snacking on soda crackers (88.5%), avoiding strong odors (75.6%), taking a prescribed antiemetic (71.3%), taking ginger (51.8%), and eliminating iron supplements (50%). Women physicians were more likely to recommend ginger and less likely to prescribe an antiemetic. For severe and sustained nausea with vomiting, with additional symptoms such as dehydration or weight loss, intravenous hydration (88.7%) and antiemetics (74.0%) were the most common treatment options. Almost half (48.8%) of respondents would hospitalize such patients. We conclude that obstetrician/gynecologists appear to be knowledgeable concerning current opinion on managing nausea and vomiting of pregnancy. Improvements in the management of nausea during pregnancy are more likely to come from further research, not education of physicians.

Knowledge and clinical practice regarding folic acid among obstetrician-gynecologists

Objective: To assess obstetrician-gynecologists’ knowledge of and clinical practice concerning folate. Methods: We mailed surveys on nutrition during pregnancy to the 230 ACOG Fellows who are members of the Collaborative Ambulatory Research Network and to a random sample of 800 Fellows who are not members of the Network. Our results focus on questions concerning folate. Results: We analyzed 488 surveys (a 47.4% response rate). Approximately two thirds of respondents screen their pregnant patients for folate intake. Fewer (53%) screen their nonpregnant patients of childbearing age. Those who screened their patients for folate intake were more likely to counsel pregnant patients about diet. They also were more likely to believe that nutritional counseling would improve pregnancy outcomes (70.0% versus 56.5%) and overall patient health (77.5% versus 66.5%). Most Fellows were aware that macrocytic anemia was a manifestation of folate deficiency (90.4%) and that folic acid supplementation during preconception and the early prenatal period helps protect against neural tube defects (96.5%). They were aware that alcoholics (91.4%), smokers (61.3%), and lactating women (53.5%) are at increased risk of folate deficiency. They were less aware of other consequences of low folate intake, such as increased serum homocysteine (20.3%). Respondents who screen their pregnant patients for folate intake correctly answered more of the knowledge questions about folate than physicians who do not screen. Conclusion: Obstetrician-gynecologists are generally aware of the link between folate intake and neural tube defects, but are less aware of other aspects of folate metabolism.

Knowledge and Clinical Practice Regarding Folic Acid Among Obstetrician-Gynecologists

In Brief Objective To assess obstetrician-gynecologists' knowledge of and clinical practice concerning folate. Methods We mailed surveys on nutrition during pregnancy to the 230 ACOG Fellows who are members of the Collaborative Ambulatory Research Network and to a random sample of 800 Fellows who are not members of the Network. Our results focus on questions concerning folate. Results We analyzed 488 surveys (a 47.4% response rate). Approximately two thirds of respondents screen their pregnant patients for folate intake. Fewer (53%) screen their nonpregnant patients of childbearing age. Those who screened their patients for folate intake were more likely to counsel pregnant patients about diet. They also were more likely to believe that nutritional counseling would improve pregnancy outcomes (70.0% versus 56.5%) and overall patient health (77.5% versus 66.5%). Most Fellows were aware that macrocytic anemia was a manifestation of folate deficiency (90.4%) and that folic acid supplementation during preconception and the early prenatal period helps protect against neural tube defects (96.5%). They were aware that alcoholics (91.4%), smokers (61.3%), and lactating women (53.5%) are at increased risk of folate deficiency. They were less aware of other consequences of low folate intake, such as increased serum homocysteine (20.3%). Respondents who screen their pregnant patients for folate intake correctly answered more of the knowledge questions about folate than physicians who do not screen. Conclusion Obstetrician-gynecologists are generally aware of the link between folate intake and neural tube defects, but are less aware of other aspects of folate metabolism. Physicians are knowledgeable about folate and neural tube defects, but are less so about other aspects of folate metabolism and its relation to health.

Knowledge and clinical practice regarding calcium nutrition among obstetrician-gynecologists.

To survey the knowledge of and attitude toward nutrition among practicing obstetrician-gynecologists, using calcium as a specific example. Our survey on calcium nutrition consisted of 29 questions divided into four categories: demographic information, professional interest and clinical practice, knowledge and opinions, and education. We mailed this survey to the 244 ACOG Fellows who are members of the Collaborative Ambulatory Research Network and to a random sample of 756 Fellows who are not members of the Collaborative Ambulatory Research Network. Most (75.4%) respondents considered making dietary recommendations an important part of their practice. Interest in nutrition was correlated significantly with its perceived importance in clinical practice and was associated with a greater self-reported likelihood of making dietary recommendations to patients and referring patients to nutritional counseling. Nutrition was of greater importance to women and to older respondents. Women were more likely to make dietary recommendations to patients. Men were more likely to recommend nonfoods and higher fat foods as sources of dietary calcium. The daily calcium intake that obstetrician-gynecologists recommended for different types of patients varied widely but did not differ between male and female respondents. The responses to the knowledge questions concerning calcium metabolism were predominantly "don't know." Although specific knowledge of calcium metabolism and regulation was incomplete, obstetrician-gynecologists generally recognized the importance of nutrition in their clinical practice. Being older and female independently increased the perceived importance of nutrition.

Knowledge and Clinical Practice Regarding Calcium Nutrition Among Obstetrician-Gynecologists

In Brief Objective To survey the knowledge of and attitude toward nutrition among practicing obstetrician-gynecologists, using calcium as a specific example. Methods Our survey on calcium nutrition consisted of 29 questions divided into four categories: demographic information, professional interest and clinical practice, knowledge and opinions, and education. We mailed this survey to the 244 ACOG Fellows who are members of the Collaborative Ambulatory Research Network and to a random sample of 756 Fellows who are not members of the Collaborative Ambulatory Research Network. Results Most (75.4%) respondents considered making dietary recommendations an important part of their practice. Interest in nutrition was correlated significantly with its perceived importance in clinical practice and was associated with a greater self-reported likelihood of making dietary recommendations to patients and referring patients to nutritional counseling. Nutrition was of greater importance to women and to older respondents. Women were more likely to make dietary recommendations to patients. Men were more likely to recommend nonfoods and higher fat foods as sources of dietary calcium. The daily calcium intake that obstetrician-gynecologists recommended for different types of patients varied widely but did not differ between male and female respondents. The responses to the knowledge questions concerning calcium metabolism were predominantly “don't know.” Conclusions Although specific knowledge of calcium metabolism and regulation was incomplete, obstetrician-gynecologists generally recognized the importance of nutrition in their clinical practice. Being older and female independently increased the perceived importance of nutrition. Among obstetrician-gynecologists, age, gender, and attitude toward nutrition influence knowledge of and clinical practice related to calcium nutrition.

Domestic Violence Screening Practices of Obstetrician-Gynecologists

In Brief Objective To ascertain the current knowledge base and screening practices of obstetrician-gynecologists in the area of domestic violence. Methods We mailed a survey to 189 ACOG Fellows who are members of the Collaborative Ambulatory Research Network. Questionnaires were also mailed to a random sample of 1250 nonmember Fellows. Results Obstetrician-gynecologists are aware of the nature of domestic violence and are familiar with common symptomatology that may be associated with domestic violence. For pregnant patients, 39% of respondents routinely screen at the first prenatal visit; 27% of respondents routinely screen nonpregnant patients at the initial visit. Screening is most likely to occur when the obstetriciangynecologist suspects a patient is being abused, both during pregnancy (68%) and when the patient is not pregnant (72%). Only 30% of obstetrician-gynecologists received training on domestic violence during medical school; 37% received such instruction during residency training. The majority (67%) have received continuing education on the subject. Years since training and personal experiences with intimate-partner violence were associated with increased screening practices. Conclusion Routine screening of all women for domestic violence has been recommended by ACOG for more than a decade. The majority of obstetrician-gynecologists screen both pregnant and nonpregnant patients when they suspect abuse. However, with universal screening, more female victims of violence can be identified and can receive needed services. Obstetrician-gynecologists know the prevalence of and adverse health consequences associated with intimate partner abuse, and slightly less than half routinely screen their patients for this problem.

Domestic violence screening practices of obstetrician-gynecologists

Objective: To ascertain the current knowledge base and screening practices of obstetrician-gynecologists in the area of domestic violence. Methods: We mailed a survey to 189 ACOG Fellows who are members of the Collaborative Ambulatory Research Network. Questionnaires were also mailed to a random sample of 1250 nonmember Fellows. Results: Obstetrician-gynecologists are aware of the nature of domestic violence and are familiar with common symptomatology that may be associated with domestic violence. For pregnant patients, 39% of respondents routinely screen at the first prenatal visit; 27% of respondents routinely screen nonpregnant patients at the initial visit. Screening is most likely to occur when the obstetrician-gynecologist suspects a patient is being abused, both during pregnancy (68%) and when the patient is not pregnant (72%). Only 30% of obstetrician-gynecologists received training on domestic violence during medical school; 37% received such instruction during residency training. The majority (67%) have received continuing education on the subject. Years since training and personal experiences with intimate-partner violence were associated with increased screening practices. Conclusion: Routine screening of all women for domestic violence has been recommended by ACOG for more than a decade. The majority of obstetrician-gynecologists screen both pregnant and nonpregnant patients when they suspect abuse. However, with universal screening, more female victims of violence can be identified and can receive needed services.

Antepartum screening in the office-based practice: Findings from the Collaborative Ambulatory Research Network

Objective : To examine utilization patterns of four antepartum screening tests by office-based obstetricians. Methods : The population surveyed was the Collaborative Ambulatory Research Network, a voluntary subset of 550 ACOG fellows from 130 practices participating in data collection regarding ambulatory practices. Responses from self-administered questionnaires concerning screening for hepatitis B, gestational diabetes, neural tube defects, and trisomy 21 were analyzed. Results : Hepatitis screening was performed by all practices with 95% (2750 of 2886) of women tested; however, only 55% (six of 11) of at-risk newborns received treatment. For gestational diabetes screening, 94% (116 of 124) administer a 50-g glucose load to all parturients, regardless of risk factors, two-thirds initiate further testing for a 1-hour post-load glucose of 140 mg/dL or greater, and 34% do so at lower glucose levels (130–135 mg/dL). For neural tube defect screening, 92% (95 of 103) offer maternal serum alphafetoprotein (MSAFP) screening although when results are elevated, further recommendations are varied. For women under 35 years of age, 84% (87 of 103) offer serum screening for trisomy 21 risk, most (68%) with double or triple (MSAFP, hCG, and estriol) markers. For women over 35 years, a majority (87%) offer serum screening, although half do so only if amniocentesis is declined for age risk alone. The relatively high initial positive rate and poor specificity of serum screening were underappreciated by a large number of respondents. Conclusion : Increased initial and continuing education of antenatal care providers is warranted if these screening tools are to perform optimally within office practices.

Antepartum screening in the office-based practice: Findings from the collaborative ambulatory research network

To examine utilization patterns of four antepartum screening tests by office-based obstetricians. The population surveyed was the Collaborative Ambulatory Research Network, a voluntary subset of 550 ACOG fellows from 130 practices participating in data collection regarding ambulatory practices. Responses from self-administered questionnaires concerning screening for hepatitis B, gestational diabetes, neural tube defects, and trisomy 21 were analyzed. Hepatitis screening was performed by all practices with 95% (2750 of 2886) of women tested; however, only 55% (six of 11) of at-risk newborns received treatment. For gestational diabetes screening, 94% (116 of 124) administer a 50-g glucose load to all parturients, regardless of risk factors, two-thirds initiate further testing for a 1-hour post-load glucose of 140 mg/dL or greater, and 34% do so at lower glucose levels (130-135 mg/dL). For neural tube defect screening, 92% (95 of 103) offer maternal serum alpha-fetoprotein (MSAFP) screening although when results are elevated, further recommendations are varied. For women under 35 years of age, 84% (87 of 103) offer serum screening for trisomy 21 risk, most (68%) with double or triple (MSAFP, hCG, and estriol) markers. For women over 35 years, a majority (87%) offer serum screening, although half do so only if amniocentesis is declined for age risk alone. The relatively high initial positive rate and poor specificity of serum screening were underappreciated by a large number of respondents. Increased initial and continuing education of antenatal care providers is warranted if these screening tools are to perform optimally within office practices.