Objective
We examined practices of obstetrician-gynecologists regarding nonvaccine-related public health recommendations during the 2009 H1N1 influenza pandemic.
Study Design
From February to May 2010, a survey was sent to a random sample of members of the American College of Obstetricians and Gynecologists involved in obstetric care.
Results
Obstetrician-gynecologists varied in their adherence to 2009 H1N1 influenza public health recommendations. Nearly all reported prescribing antiviral medications to pregnant women with suspected influenza. Most obstetrician-gynecologists reported using preventive practices in the outpatient setting to reduce exposure of well patients to ill ones. A wide range of responses was provided regarding postpartum infection control practices, suggesting lack of awareness of, disagreement with, or difficulty adhering to these recommendations.
Conclusion
Obstetrician-gynecologists reported that they adhered to some recommendations related to 2009 H1N1 influenza, but not to others. These data provide insight into strategies for development and dissemination of recommendations in a future pandemic.
Pregnant women have been shown to be at increased risk for influenza-associated complications during influenza seasons and previous influenza pandemics. During the influenza A(H1N1)pdm09 (2009 H1N1) pandemic, pregnant women were 4 times more likely to be hospitalized than persons in the general population, and accounted for a disproportionate number of deaths. Treatment within the first 2 days after symptom onset was associated with a lower risk of admission to an intensive care unit and death.
Vaccination is the best way to prevent influenza and its complications among pregnant women and infants less than 6 months of age, and results regarding attitudes and practices of obstetrician-gynecologists regarding influenza vaccination during the 2009 H1N1 pandemic were published recently. However, 2009 H1N1 vaccine did not become available until several months after the first cases of 2009 H1N1 were recognized in the United States. Before that time, nonpharmaceutical interventions, infection control guidelines, and antiviral treatment and chemoprophylaxis were the primary strategies to prevent influenza-associated complications.
During the 2009 H1N1 pandemic, public health recommendations specific to pregnant women regarding nonpharmaceutical interventions, infection control in the inpatient and outpatient settings, influenza diagnostic testing, antiviral treatment and prophylaxis, as well as those related to influenza vaccine against seasonal and 2009 H1N1 influenza were developed by the Centers for Disease Control and Prevention (CDC). Guidelines on nonpharmaceutical interventions for prevention of influenza included recommendations for frequent hand hygiene and respiratory etiquette, and avoidance of ill people. Within health care outpatient settings, clinicians were advised to identify and isolate ill patients to prevent exposure to well patients and to provide facemasks for ill patients. In the hospital during labor and delivery and postpartum, clinicians were advised to limit visitors (ie, allow the presence only of healthy adults who are necessary for the woman’s emotional well-being and care in labor and delivery), have ill mothers wear facemasks during labor and delivery, temporarily separate ill mothers from their healthy newborns, and have the mother express breast milk for infant feeding by a healthy caregiver. CDC recommended empiric treatment with oseltamivir of pregnant women who presented with suspected or confirmed influenza, and emphasized that treatment decisions should be based on suspicion of influenza, rather than on diagnostic testing, given the low sensitivity of rapid influenza diagnostic tests and the time necessary for more definitive testing to be completed. CDC guidelines during the pandemic also stated that chemoprophylaxis could be considered for pregnant women who had close contact with a person with suspected or confirmed influenza.
These public health recommendations specific to pregnant women were vigorously communicated to health care providers, including obstetrician-gynecologists, through close collaborative efforts with key partners such as the American College of Obstetricians and Gynecologists (ACOG) and a wide variety of mechanisms (eg, internet, webinars, emails, publications). The practices of obstetrician-gynecologists in the United States regarding nonvaccine-related public health recommendations during the pandemic have not yet been examined. In this study, we present results of a survey of ACOG members who provided obstetric care regarding their practices related to public health recommendations during the 2009 H1N1 pandemic (excluding those related to vaccines).
Materials and Methods
To determine practices of obstetrician-gynecologists regarding strategies to prevent influenza used in outpatient and inpatient settings, influenza diagnostic testing, and antiviral treatment and prophylaxis, we mailed a survey to a nationally representative sample of 3116 obstetrician-gynecologists selected randomly from a sample of 33,685 practicing obstetrician-gynecologists who were Fellows or Junior Fellows of ACOG. Obstetrician-gynecologists currently involved in obstetric care were eligible to participate; others were asked to return the survey without responding. Obstetrician-gynecologists received the survey, a cover letter, and a prepaid envelope; participants were not offered an incentive to participate. The first mailing was sent in February 2010, with second, third, and fourth mailings sent to nonrespondents at 4- to 5-week intervals. The survey consisted of 33 questions about basic demographics of respondents and their patients, and practices regarding public health recommendations for pregnant women regarding influenza. Five weeks after the fourth mailing, a short follow-up survey with 6 questions was sent to nonrespondents to assess nonresponse bias by comparing the responses of respondents and nonrespondents.
Analyses were performed using SAS version 9.1 (SAS Institute Inc., Cary, NC) and SPSS version 16.0 (SPSS Inc., Chicago, IL). We calculated frequencies of responses to each survey question, excluding nonresponses from the denominators for each question. To compare differences in responses for the 2008-2009 and 2009-2010 influenza seasons, 2-sided χ 2 tests and a significance level of P ≤ .05 were used.
This project was reviewed for human subject concerns by CDC and ACOG and was deemed to be exempt from institutional review board review.
Results
Of the 3116 surveys mailed, 20 were returned as undeliverable. Among the obstetrician-gynecologists who received the survey, 2 refused to participate and 1310 returned the survey, for a response rate of 42.3% (1310/3096). Of those providers who returned the surveys, 437 (33.4%) responded that they did not provide obstetric care during the 2009-2010 influenza season; thus, responses from 873 eligible participants are included in this analysis.
The mean age of respondents was 48.9 years, mean duration of clinical practice was 16.7 years, and 51.1% of respondents were female ( Table 1 ). Nearly half of the respondents practiced in a group obstetrician-gynecologist setting, and nearly all respondents considered primary care/preventive medicine as either a very important or important part of their practice. Respondents were asked to estimate the proportion of their patients eligible for Medicaid and the mean was 33.4%. Respondents were also asked about the race-ethnicity of patients in their practices; responses showed that over half of patients were non-Hispanic white ( Table 1 ).
| Characteristics | Percentage a or mean (range) |
|---|---|
| Sex, % | |
| Female | 51.1 |
| Male | 48.9 |
| Average age, y | 48.9 (29.7–84.6) |
| Average years in practice, y | 16.7 (0.5–52) |
| Type of practice, % | |
| Group obstetrician-gynecologist practice | 48.1 |
| Solo practice | 16.4 |
| Multispecialty group | 12.4 |
| University full-time faculty and practice | 11.2 |
| Other | 11.9 |
| Consider primary care/preventive medicine an important part of practice, % | |
| Very important | 45.8 |
| Important | 49.4 |
| Not important | 3.8 |
| Average estimated % of patients eligible for Medicaid | 33.4 |
| Average estimated % of patients of certain race/ethnicity | |
| Non-Hispanic white | 54.9 |
| Non-Hispanic black | 15.2 |
| Hispanic | 17.8 |
| Asian/Pacific Islander | 5.3 |
| Native American | 1.3 |
| Multiracial | 2.6 |
| Other | 1.0 |
Respondents reported using several preventive practices in outpatient obstetric settings more often during the 2009-2010 season than during the 2008-2009 influenza season. More than half of providers reported rescheduling routine appointments for pregnant patients with influenza-like illness (ILI) until they were healthy, questioning patients about recent ILI symptoms so that those with suspected ILI could be separated from healthy women, and asking patients with ILI to wear facemasks in the waiting area during the 2009-2010 season ( Table 2 ). Obstetrician-gynecologists also reported discussing preventive measures with pregnant patients more often during the 2009-2010 season than during the 2008-2009 season, including social distancing (eg, minimizing contact with sick individuals), frequent handwashing, cough etiquette, early symptom recognition, and prompt treatment of fever with fever-reducing medications ( Table 2 ).
| Practices | 2008-09 influenza season, % | 2009-10 influenza season, % | P value |
|---|---|---|---|
| Preventive practices used in outpatient settings | |||
| Calling scheduled patients before appointment to ask about recent symptoms of ILI | 2.1 | 4.4 | < .05 |
| Referring pregnant patients with ILI symptoms to primary care provider for treatment | 34.9 | 40.6 | NS |
| Rescheduling routine appointments for pregnant patients with ILI until they are healthy | 30.7 | 51.2 | < .0001 |
| Questioning arriving patients about recent ILI symptoms and separating those with suspected ILI from those that are healthy | 35.9 | 65.5 | < .0001 |
| Asking patients with ILI to wear facemasks in waiting area | 28.0 | 59.6 | < .0001 |
| Always/frequently discuss specific preventive measures with pregnant women | |||
| Discuss social distancing (eg, minimizing contact with ill individuals, avoiding crowded public gatherings) | 58.0 | 79.2 | < .0001 |
| Promote frequent hand washing | 63.0 | 87.6 | < .0001 |
| Discuss cough etiquette | 43.7 | 62.7 | < .0001 |
| Discuss early symptom recognition | 51.7 | 76.6 | < .0001 |
| Discuss prompt treatment of fever with fever-reducing medicines | 57.7 | 75.9 | < .0001 |
With regard to infection control during labor and delivery ( Table 3 ), nearly 80% of obstetrician-gynecologists reported that they questioned patients about the presence of flu-like symptoms “most of the time,” and nearly all reported separating ill from healthy patients during labor and delivery. However, fewer respondents reported asking ill patients to wear a surgical mask during labor and delivery or required ill mothers to wear a mask before holding their healthy newborns immediately after delivery “most of the time.” More than 80% of responding obstetrician-gynecologists reported limiting visitors to healthy persons who were necessary for the patient’s emotional well-being ( Table 3 ).
| Practices a | Most of the time | Sometimes | Rarely or never | Unsure |
|---|---|---|---|---|
| Labor and delivery | ||||
| Questioning patients about recent flu-like symptoms | 79.4% | 12.7% | 3.1% | 4.8% |
| Isolating ill patients from healthy patients during labor and delivery | 91.6% | 4.5% | 2.1% | 1.9% |
| Asking ill patients to wear a surgical mask during labor and delivery | 73.9% | 9.8% | 10.5% | 5.7% |
| Requiring ill mothers to wear a surgical mask before holding their healthy newborns immediately after delivery | 57.7% | 12.2% | 20.2% | 9.8% |
| Limiting visitors to healthy persons who are necessary for the patient’s emotional well-being and care | 81.6% | 10.4% | 5.5% | 2.5% |
| Postpartum | ||||
| Separating ill mother from her healthy newborn immediately after delivery | 23.6% | 16.9% | 40.8% | 18.7% |
| Rooming-in between convalescent mother and her healthy newborn after delivery with no precautions | 18.7% | 14.2% | 39.1% | 28.1% |
| Rooming-in between convalescent mother and her healthy newborn after delivery under droplet precautions | 31.5% | 22.5% | 14.8% | 31.1% |
| Healthy newborn is separated from ill mother and moved to well infant nursery in proximity to other newborns | 13.7% | 12.4% | 36.9% | 37.0% |
| Healthy newborn is separated from ill mother and moved to well infant nursery but apart from other newborns | 15.2% | 15.2% | 29.3% | 40.4% |
| Healthy newborn is separated from ill mother and moved to special care nursery | 9.3% | 9.7% | 43.1% | 38.0% |
| Healthy newborn is separated from ill mother and moved to NICU | 6.2% | 6.1% | 50.9% | 36.8% |
| Infant feeding | ||||
| Discouraging ill mothers from breastfeeding their healthy newborns (directly or via expressed milk) | 6.5% | 7.5% | 63.8% | 22.2% |
| Encouraging ill mothers to express breast milk to enable a well person to feed their infant | 19.4% | 19.3% | 32.1% | 29.3% |
| Encouraging ill mothers to wear a face mask while directly breastfeeding their healthy newborns | 43.9% | 19.0% | 14.1% | 23.0% |
| Encouraging ill mothers to wash their hands with soap and water before breastfeeding | 75.0% | 7.0% | 3.0% | 15.1% |
| Encouraging ill mothers to observe respiratory etiquette guidelines | 69.4% | 10.9% | 3.1% | 16.6% |
a For women with suspected or confirmed influenza-like illness.
When asked about postpartum infection control guidelines ( Table 3 ), about 40% of obstetrician-gynecologists reported rarely or never separating ill mothers from their healthy newborns immediately after delivery. More than half of obstetrician-gynecologists reported allowing rooming-in between a convalescent mother and her healthy newborn after delivery under droplet precautions either most of the time or sometimes. “Most of the time” was selected by more than 10% of obstetrician-gynecologists in response to several different postpartum options, including allowing rooming-in between a convalescent mother and her healthy newborn after delivery with no precautions, separating a healthy newborn from an ill mother and moving the infant to the well infant nursery in proximity to other newborns, and separating a healthy newborn from an ill mother and moving the infant to the well infant nursery but apart from other newborns.
The majority of obstetrician-gynecologists reported that they encouraged ill mothers to wear a facemask while directly breastfeeding their healthy newborns either most of the time or sometimes ( Table 3 ). Obstetrician-gynecologists also frequently reported encouraging mothers to wash their hands with soap and water before breastfeeding and to observe respiratory etiquette guidelines. Obstetrician-gynecologists less commonly reported that they encouraged ill mothers to express breast milk to enable a well person to feed their infant either most of the time or sometimes. When asked about influenza diagnostic testing practices ( Table 4 ), more than half of obstetrician-gynecologists reported relying on clinical diagnosis, although about a third reported using rapid influenza diagnostic testing for a pregnant woman presenting with symptoms of influenza. More than half said that they were less likely to or would not prescribe antiviral medications to a patient with negative rapid test results ( Table 4 ). Rapid tests were used more commonly for pregnant women with underlying conditions than for healthy pregnant women. Nearly all obstetrician-gynecologists reported that they prescribed antiviral treatment to pregnant women based on clinical evaluation; however, 8.7% reported that they would treat low-risk pregnant women only after test results confirmed influenza ( Table 5 ). Obstetrician-gynecologists were significantly less likely to base their treatment decisions on test results in high-risk women (women with underlying conditions in addition to pregnancy). Most obstetrician-gynecologists reported having no or only slight concerns about the safety of antiviral medications for the pregnant woman or her fetus. Most obstetrician-gynecologists did not recommend chemoprophylaxis for high- or low-risk women with a possible exposure at a public event. The majority of obstetrician-gynecologists reported offering antiviral prophylaxis to a patient with a household member ill with confirmed or suspected 2009 H1N1 influenza, to a patient who provides care to patients and has an exposure, and to a teacher with an exposure in the elementary school or day care setting. Obstetrician-gynecologists reported being significantly more likely to offer antiviral chemoprophylaxis to a high-risk patient than a low-risk patient.
| Practices | % |
|---|---|
| Diagnostic test most likely to use for pregnant patient presenting with fever (>100° F) and cough and/or sore throat | |
| Rapid antigen test | 33.2 |
| DFA | 2.0 |
| RT PCR for seasonal flu | 7.8 |
| RT PCR for H1N1 | 14.9 |
| Viral culture | 4.8 |
| IgG and IgM | 2.7 |
| Clinical diagnosis | 55.3 |
| Interpreting on-site rapid antigen testing for influenza | |
| With a negative test result, I would not prescribe antivirals | 9.3 |
| With a negative test result, I am less inclined to prescribe antivirals | 44.0 |
| I do not use a negative test result to make a decision about prescribing antivirals | 46.8 |
| Always or frequently ordering rapid influenza diagnostic test for suspected influenza-like illness in specific groups of pregnant patients | |
| Healthy pregnant women | 29.1 |
| Pregnant patients with underlying chronic condition | 40.7 |
| Pregnant patients with prepregnancy obesity | 31.9 |
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