Role of Physician Gender in the Modern Practice of Obstetrics and Gynecology: Do Obstetrician-Gynecologists Perceive Discrimination from their Sex?

OBJECTIVES: It is unclear whether obstetrician-gynecologists (OBGYNs) experience gender discrimination as a result of patient and organizational gender preferences. Our objective was to evaluate whether the gender preference for OBGYNs resulted in perceptions of discrimination by the physician while simultaneously assessing their patients' views for choosing their OBGYN. METHODS: A survey assessed whether OBGYNs' perceptions of patients and employers' preferences for gender in selecting an OBGYN affected their clinical practice and resulted in feelings of discrimination. Providers' patients simultaneously completed a survey to explore the role of gender in the selection of their OBGYN. The Mann-Whitney U test was used for comparisons. A P < 0.05 was considered statistically significant. RESULTS: Thirty-four physicians (97% response rate) and 803 patients (81% response rate) completed the survey. The majority of male physicians agreed that their gender negatively affects their patient practice volume (60%), whereas no female physicians agreed with this statement (0%, P < 0.01). Female physicians were more likely to agree (46%) that they are discriminated against because of gender in terms of salary as compared with male physicians (20%, P = 0.049), however. Although more women who see a female OBGYN (compared with those who see a male OBGYN) perceive that their physician's gender is important to them (62% versus 20%, P < 0.01), the most frequent reason all women chose their OBGYN is the "rating" of the physician. CONCLUSIONS: Female and male OBGYNs perceive bias because of their gender; however, the former is because of compensation and the latter is because of patient preferences. The majority of women choose their OBGYN based on the physician's rating and not on the physician's sex, however.

Effect of Vitamin D Supplementation on 25(OH)D Status in Elite Athletes With Spinal Cord Injury.

Recent studies suggest that a substantial proportion of athletes with spinal cord injury have insufficient 25(OH) vitamin D (25(OH)D) status, which may be associated with decreased muscle strength. This study consisted of two parts: (a) to examine the effects of a 12- to 16-week vitamin D3 supplementation protocol on 25(OH)D concentration and (b) to determine whether subsequent 25(OH)D status impacts muscle performance in elite athletes with spinal cord injury. Thirty-four members (age: 33 ± 15 years, weight: 69.6 ± 28.2 kg, and height: 170.2 ± 25.4 cm) of the U.S. and Canadian Paralympic program participated in the study. 25(OH)D concentrations and performance measures (handgrip strength and 20-m wheelchair sprint) were assessed pre- and postsupplementation. Participants were assigned a vitamin D3 supplementation protocol based on initial 25(OH)D concentrations. Participants with deficient 25(OH)D status (<50 nmol/L) received 50,000 IU/week for 8 weeks, and participants with insufficient status (50-75 nmol/L) received 35,000 IU/week for 4 weeks, after which both received a maintenance dose of 15,000 IU/week. Participants with sufficient status (>75 nmol/L) received the maintenance dose of 15,000 IU/week. 25(OH)D concentrations increased significantly (p < .001; 66.3 ± 24.3 nmol/L and 111.3 ± 30.8 nmol/L pre- and postsupplementation, respectively). About 26% of athletes had sufficient 25(OH)D concentrations presupplementation, and 91% had sufficient concentrations postsupplementation. About 62% of participants improved handgrip strength postsupplementation with no change in 20-m wheelchair sprint performance. The supplementation protocol was effective for achieving sufficient vitamin D concentrations in elite athletes with spinal cord injury.

Prenatal depression screening and antidepressant prescription: obstetrician-gynecologists' practices, opinions, and interpretation of evidence.

Obstetrician-gynecologists (ob-gyns) are well-positioned to detect symptoms of perinatal depression; however, little is known about how ob-gyns respond. The purpose of this study was to evaluate ob-gyns' beliefs and practices related to prenatal depression screening and antidepressant prescription during pregnancy. A larger survey on prenatal medication was developed at the American College of Obstetricians and Gynecologists (ACOG) and distributed to a sample of 1000 Fellows. The overall response rate was 37.9% (N = 379). Two hundred eighty-eight provided care to pregnant patients and therefore, responded to questions on prenatal depression screening and antidepressant prescription. 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, only 31.9% prescribed non-SSRIs. Ob-gyns felt comfortable prescribing SSRIs (78.1%) and counseled patients that 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 to pregnant patients was not significantly associated with interpretation of evidence on fetal and neonatal outcomes. Findings suggest most ob-gyns in the USA at least sometimes prescribe antidepressants in response to patient reports of depression symptoms during pregnancy. Mixed interpretations of evidence regarding the effects of SSRIs on fetal and neonatal outcomes reflect a critical need for high-quality safety data upon which to base treatment recommendations.

Provider and Patient Knowledge and Views of Office Practices on Weight Gain and Exercise during Pregnancy.

OBJECTIVE: This study sought to assess provider and patient knowledge and beliefs on gestational weight gain (GWG) and exercise during pregnancy, outline current clinical practices and the perceived value of educational tools. STUDY DESIGN: Providers and patients at the George Washington Medical Faculty Associates Obstetricians and Gynecologists clinic were recruited for a voluntary survey. Descriptive statistics of responses were compared and chi-square analysis tested for significant associations. RESULTS: A total of 461 patient and 36 provider questionnaires were analyzed. Providers recommended GWG consistent with the Institute of Medicine guidelines for a "normal" body mass index (82.9%); however, a majority (52.8%) recommended GWG below guidelines for obese women. All providers reported counseling patients on GWG, but only 53.4% of patients reported discussing personal recommendations. About half of providers reported distributing educational materials for GWG (60.0%); however, only 30.6% of patients reported receiving them. African American patients self-reported receiving the highest rates of counseling and educational materials, though a lower rate of recommendations to exercise. Patients perceived educational tools to be more useful than did providers. CONCLUSION: Our findings suggest a gap between provider-patient perceptions regarding counseling and provision of informational materials. Future research should study whether implementing various educational tools might increase the efficacy of current practices.

Influenza Vaccination among Pregnant Women: Patient Beliefs and Medical Provider Practices.

ACOG's research department recruited four medical centers to participate in a study on the attitudes and practices of medical providers and pregnant patients regarding influenza vaccination. Medical providers and patients were given voluntary surveys and medical record data was collected over two flu seasons, from 2013 to 2015. Discrepancies between self-reports of medical providers and patients and medical records were observed. Nearly 80% of patients self-reported accepting the influenza vaccine, but medical record data only reported 36% of patients accepting the vaccine. Similarly, all medical providers reported giving recommendations for the vaccine, but only 85% of patients reported receiving a recommendation. Age, education, a medical provider's recommendation, and educational materials were found to positively influence patient beliefs about the influenza vaccine. Accepting the vaccine was influenced by a patient's previous actions, beliefs, and a medical provider's recommendation. Patients who reported previously not accepting the vaccine and had negative feelings towards the vaccine but accepted it while pregnant reported concern for the health and safety of their baby. Future research should focus on groups that may be less likely to accept the vaccine and ways to dispel negative myths. Medical provider should continue to strongly recommend the vaccine and provide educational materials.

The binding and specificity of chemokine binding proteins, through the lens of experiment and computation.

Chemokines are small proteins that are critical for immune function, being primarily responsible for the activation and chemotaxis of leukocytes. As such, many viruses, as well as parasitic arthropods, have evolved systems to counteract chemokine function in order to maintain virulence, such as binding chemokines, mimicking chemokines, or producing analogs of transmembrane chemokine receptors that strongly bind their targets. The focus of this review is the large group of chemokine binding proteins (CBP) with an emphasis on those produced by mammalian viruses. Because many chemokines mediate inflammation, these CBP could possibly be used pharmaceutically as anti-inflammatory agents. In this review, we summarize the structural properties of a diverse set of CBP and describe in detail the chemokine binding properties of the poxvirus-encoded CBP called vCCI (viral CC Chemokine Inhibitor). Finally, we describe the current and emerging capabilities of combining computational simulation, structural analysis, and biochemical/biophysical experimentation to understand, and possibly re-engineer, protein-protein interactions.

Oral and IUD emergency contraception provision among a national sample of obstetrician-gynecologists.

OBJECTIVE: To assess obstetrician-gynecologists' practices related to emergency contraception (EC). We performed a survey of ACOG Fellows and Junior Fellows between August 2016 and March 2017. RESULTS: The final sample was 1280 respondents (52.2% response rate). The majority (84%) reported offering at least one form of EC, with 18% offering ulipristal acetate and 29% offering copper IUDs. Fifty-seven percent of those offering IUDs reported recommending them in the last 12 months. Few had placed IUDs for EC. Half of ob-gyns reported not recommending copper IUDs because patients rarely seek EC. CONCLUSION: Many obstetrician-gynecologists are not offering the most effective forms of EC. IMPLICATIONS: Both patients and clinicians need more outreach about the most effective methods of emergency contraception.

Obstetricians' knowledge and practices regarding the management of preeclampsia.

Background: Preeclampsia affects over 4% of pregnancies in the United States. Management of preeclampsia is dependent on the severity of the condition and can range from expectant management to early delivery and inpatient observation. After publication of the hypertension in Pregnancy Task Force guidelines in 2013, little is known about their implementation and acceptance by practicing obstetricians and maternal-fetal medicine (MFM) specialists.Objective: To evaluate Obstetricians' knowledge and practices regarding the management of preeclampsia.Methods: A prospective survey was administered to ob-gyns at three different hospital systems in the Northeastern United States to assess practices regarding preeclampsia management and prevention.Results: A total of 87 out of 130 providers completed and returned a questionnaire (66.9% response rate). Providers with a subspecialty in MFM made up 44.3% of the sample. 90.7% of respondents agreed that preeclampsia is a common diagnosis in their practice, while 85% agreed that aspirin is useful for reducing a patient's risk of preeclampsia. 68.8% of providers reported not administering magnesium sulfate in labor to reduce seizure risk in patients with preeclampsia without severe features. Only 5.8% of providers reported using a preeclampsia prediction algorithm, all of whom were MFMs. Providers who specialized in MFM were more likely to prescribe aspirin for preeclampsia prevention in patients with chronic hypertension (26, 74.3% vs. 17, 39.5%, p = .002). MFM specialists were also more likely to counsel patients with abnormal biomarkers on the risk of preeclampsia (23, 69.7% vs. 15, 35.7%, p = .005).Conclusion: Efforts to inform practicing ob-gyns about the best practices for preeclampsia management and prevention have been largely successful, though there are still discrepancies between current recommendations and practice. Differences between general OBGYNs and MFM specialists were also significant with regards to practice. Given the acknowledgement of how common diagnoses of preeclampsia are in respondents' practices, better education and distribution of guidelines on management of preeclampsia is needed.

Obstetrician-gynecologists' practices and attitudes on substance use screening during pregnancy.

OBJECTIVE: To describe obstetrician-gynecologists' practices and attitudes related to substance use screening in pregnant patients. STUDY DESIGN: A 2017 cross-sectional survey assessed US obstetrician-gynecologists' (n = 462; response rate = 34%) practices (substance use screening frequency and methods) and attitudes (practice priority of screening, confidence in treating, and responsibility statements). Chi-squared tests and adjusted modified Poisson regression were used to estimate associations between practices and attitudes. RESULTS: Of 353 respondents with screening information, 79% frequently screen for substance use and 11% used a validated instrument. Confidence was the highest for treating pregnant patients using tobacco (81%). Respondents whose practices make it a high priority to screen for all substances were 1.2 times as likely to frequently screen as their counterparts (95% CI: 1.1-1.3). CONCLUSIONS: Four out of five obstetricians-gynecologists reported a high frequency of substance use screening in pregnant patients. Findings highlight the importance of increasing priority of substance use screening by obstetrician-gynecologists.

Implementing best practices for the provision of long-acting reversible contraception: a survey of obstetrician-gynecologists.

OBJECTIVE: To examine obstetrician-gynecologists' practices regarding provision of long-acting reversible contraceptive (LARC) methods same-day, immediately postpartum, or to women under age 21. STUDY DESIGN: Between August 2016 and March 2017, the American College of Obstetricians and Gynecologists (ACOG) sent 2500 of their members an electronic survey questionnaire regarding the provision of LARC methods. ACOG mailed nonresponders paper surveys. RESULTS: After exclusions, the final sample was 1280 respondents (52.2% response rate). Although 91% of obstetrician-gynecologists reported providing IUDs, only 29% (95% CI, 26-32%) offered same-day placement. Ninety-two percent (95% CI, 90-94%) offered IUDs to eligible patients under age 21. Nineteen percent (95% CI, 16.1-21.3%) offered immediate postpartum IUD placement and 21% (95% CI, 18-23%) offered immediate postpartum implant placement. Obstetrician-gynecologists practicing in states where Medicaid reimbursed for immediate postpartum LARC devices within the global fee for delivery (versus separate reimbursement) had lower odds of offering them. CONCLUSION: While most ob-gyns are offering IUDs to women under age 21, many are still not offering them same-day. A minority of ob-gyns offer either IUDs or implants immediately postpartum, and there are important geographic and practice setting disparities in this practice. IMPLICATIONS: Efforts to align LARC practices with published evidence and improve access to LARC methods for women desiring them will require a multipronged effort including continuing education of physicians, patient education and outreach, as well as advocacy to improve insurance coverage and reimbursement.

Opioid Knowledge and Prescribing Practices Among Obstetrician-Gynecologists.

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], P=.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.

Patient attitudes toward influenza and tetanus, diphtheria and acellular pertussis vaccination in pregnancy.

BACKGROUND: Routine influenza and tetanus, diphtheria and acellular pertussis (Tdap) vaccination of pregnant women to prevent poor maternal, fetal and neonatal outcomes is recommended practice; however, actual rates of influenza vaccine acceptance are typically well below the (Healthy People 2020, 2015) goal of 80%. OBJECTIVE: We sought to identify barriers to accepting either vaccination. MATERIALS AND METHODS: From December 2014 to April 2015 women were given a questionnaire eliciting their experiences, attitudes and history of influenza and Tdap vaccination in pregnancy during their routine prenatal care appointments at a tertiary care center. Patient demographics were included in the questionnaire. A similar questionnaire was administered to prenatal care providers. Patient influenza and Tdap vaccination acceptance rates were compared and predictors of vaccine acceptance were analyzed with bivariate logistic regression. RESULTS: Out of the 400 patient questionnaires distributed, 338 (84.5%) were completed and returned; 24 of 45 (53.3%) provider questionnaires were returned. Vaccination acceptance rates were 70.7% for the influenza vaccine and 76.3% for the Tdap vaccine. The logistic regression model indicated that predictors of acceptance for either vaccine in pregnancy are patient attitude and previous vaccination history. Patient attitudes were more favorable towards Tdap than influenza vaccination. The combination of healthcare provider recommendation and educational materials was significantly predictive of both Tdap and influenza vaccine acceptance. The most common reasons given for declining the influenza vaccine were safety concerns; the most common reasons given for declining the Tdap vaccine were that patients did not think it was required again when they received the vaccine before pregnancy. CONCLUSIONS: Our study suggests that providers can improve Tdap and influenza vaccination acceptance in pregnancy by recommending the vaccination in combination with provision of educational materials on the vaccines.

A survey of honor-related practices among US obstetricians and gynecologists.

OBJECTIVE: To assess patterns of honor-related practices-including virginity testing, virginity restoration, and female genital mutilation (FGM)-among US obstetrician-gynecologists (OBGYNs). METHODS: Between June 1 and August 31, 2016, 1000 members of the American College of Obstetricians and Gynecologists were invited by email to complete an anonymous online survey. The survey comprised 42 questions evaluating the demographic and practice characteristics of the respondents. RESULTS: Overall, 288 of the 909 practicing US OBGYNs with functioning email addresses completed the survey (31.7% response rate). In the 12 months before the survey, 168 (58.3%) respondents had provided care to one or more patients who had previously undergone FGM. Care was also provided for patients who requested virginity testing or virginity restoration by 29 (10.1%) and 16 (5.6%) respondents, respectively. Ten (3.5%) respondents performed virginity testing on request, whereas 3 (1.0%) performed virginity restoration. CONCLUSION: Some respondents performed honor-related practices, which indicated a need to educate all practicing US OBGYNs about their ethical and legal obligations in the care of such patients.