Materials and Methods

The study was a national mail survey to 1500 US obstetricians, selected through simple random sampling from the American Medical Association (AMA) Physician Masterfile and confirmed to hold an active US medical license. The Physician Masterfile includes data on all US physicians, including both those who are AMA members and those who are not. It also includes data for graduates of foreign medical schools who live in the United States. Physicians were initially sent the 51-question survey along with a paid return envelope and a $2 token incentive. Over 2 months, nonresponders were sent up to 2 additional copies of the survey. If an envelope was returned undeliverable, the subject was randomly replaced. The sample size was selected to have adequate power assuming a 50% response rate.

The survey included questions about care at the time of perinatal death, opinions about subsequent conception and pregnancy after perinatal death, personal impact of caring for patients with a loss, and demographic variables. This study was approved by the University of Michigan Institutional Review Board.

Analysis of the results was conducted using software (Stata SE, version 10; Stata Corp, College Station, TX). Bivariable regression was performed to evaluate associations between outcomes of interest and the following covariates: years of experience, race, sex, professional position, personal or family experience with a perinatal loss, being a parent, and current practice of obstetric deliveries. Multivariable logistic regression including all of these covariates was also performed to control for potential confounders. Years of experience and sex were tested as an interaction term and found not significant.

Results

Of 1500 mailings, 19 subjects were replaced due to undeliverable envelopes and 15 mailings came back undeliverable after the study ended and these subjects were not replaced. Of the remaining 1485 subjects, 34 physicians returned a form declining to participate, 2 incompletely filled out the survey, and 804 completed the full survey for a usable response rate of 54%.

Respondents were nearly equally split between male and female, and median age was 46 years with 14 years of practice after residency ( Table 1 ). In all, 86% were attending physicians and 14% were residents and fellows. A total of 82% currently participated in labor and delivery of pregnant women. Racial distribution, age, and average number of obstetric deliveries were comparable to the US distribution of obstetricians. Age and years of experience postresidency were collinear, so only physician age was used in multivariable regressions. No other variables were collinear.

Physicians were questioned about the advice they give parents about when to start trying to conceive another pregnancy after a perinatal loss ( Table 2 ). They were asked to assume a scenario in which a patient experienced a third-trimester fetal demise, had a vaginal delivery, and had no outstanding medical issues or testing that needed to be investigated or resolved prior to the next pregnancy. To the question: “On average, when do you tell parents is the earliest they should start trying?” 27% reported that parents could try “as soon as they feel ready”; 10% recommended waiting for ≥1 normal menses; 33% recommended 2-5 normal menses; and 31% advised waiting ≥6 months. Bivariable analysis identified no significant differences between groups recommending >6 months or <6 months of waiting in terms of age, sex, race, being a parent, position (resident, fellow, attending), or currently practicing obstetrics. However, multivariable logistic regression controlling for all of these covariates indicated that women were slightly less likely to recommend a waiting period of ≥6 months (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.41–0.92; P = .02).

Additional analysis was performed to evaluate characteristics of the 37% of physicians who endorsed very short waiting times (advising parents to try again for pregnancy as soon as they feel ready or with just ≥1 normal menses) compared with other physicians. There were no significant differences in bivariable analysis for any of the major covariates or between obstetric generalists and those with specialty training. In multivariate regression, female sex was significant although the 95% CI was close to 1 (OR, 1.02; 95% CI, 1.01–2.00; P = .044).

To distinguish between advice that might reflect accommodation of parental emotional needs vs their medical needs, subjects were asked a series of follow-up questions: “On average, when do you believe parents are emotionally ready to try?” For this question, 45% of physicians reported parents would not be emotionally ready to try again until ≥6 months; 40% answered “as soon as they feel ready”; 1% reported the need for ≥1 normal menses; and 13% reported the need for 2-5 normal menses. There was no significant difference between groups recommending >6 months or <6 months for emotional readiness in terms of the major covariates in either bivariable or multivariable analysis.

When asked: “On average, when do you believe parents are medically ready to try?” just 32% of physicians responded that parents would not be medically ready until ≥6 months; 9% reported readiness “as soon as they feel ready”; 19% after ≥1 normal menses; and 40% after 2-5 normal menses. In bivariable analysis, older physicians and parents were more likely to endorse waiting times <6 months for medical reasons. In multivariable logistic regression, those answering <6 months were just slightly more likely to be older (OR, 1.03; 95% CI, 1.01–1.05; P = .001) and female (OR, 1.43; 95% CI, 1.01–2.03; P = .046), although 95% CIs for both variables were very near to 1. Being a parent was not significant in multivariable regression.

Respondents were also queried to see whether, in their experience, parents wait to try for another pregnancy for as long a period as the physician has recommended. In all, 42% answered that parents “often” or “usually” wait as long as suggested, 13% reported parents “rarely” or “not so often,” waited, and 44% selected “it varies.” In bivariable analysis, older age; being male, a fellow, and a parent; and personal experience with loss predicted an answer of “often” or “usually.” In multivariable regression, only fellows (OR, 2.62; 95% CI, 1.04–6.60; P = .041) and parents (OR, 1.68; 95% CI, 1.06–2.65; P = .027) were more likely to report that parents often or usually waited as long as suggested.