Objective
We sought to describe health care provider knowledge, attitudes, and treatment preferences for early pregnancy failure (EPF).
Study Design
We surveyed 976 obstetrician/gynecologists, midwives, and family medicine practitioners on their knowledge and attitudes toward treatment options for EPF, and barriers to adopting misoprostol and office uterine evacuations. We used descriptive statistics to compare practices by provider specialty and logistic regression to identify associations between provider factors and treatment practices.
Results
Seventy percent of providers have not used misoprostol and 91% have not used an office uterine evacuation to treat EPF in the past 6 months. Beliefs about safety and patient preferences, and prior induced abortion training were significantly associated with use of both of these treatments.
Conclusion
Increasing education and training on the use of misoprostol and office uterine evacuation, and clarifying patient treatment preferences may increase the willingness of providers to adopt new practices for EPF treatment.
During their lifetime, about 25% of women will experience an early pregnancy failure (EPF). The term “early pregnancy failure” refers to an abnormal first-trimester intrauterine pregnancy, including anembryonic gestation, and embryonic or fetal demise. Effective and safe EPF treatment includes expectant management, medical treatment with misoprostol, or surgical evacuation in either an office or operating room setting. Previous studies have demonstrated that all treatment options are accepted by women. As all the treatment options are reasonable, patient preferences should play a dominant role in treatment choice.
For Editors’ Commentary, see Table of Contents
Adherence to evidence-based practices or widely available published care guidelines is suboptimal in general, and in women’s health specifically. Practitioners are often slow to adopt new treatments, even when such options are known to be effective, safe, and even superior to conventional treatments. This is troubling because clinicians are a powerful influence on treatment selection in many clinical situations, including EPF. In the case of EPF treatment, it is not clear that all treatment options are routinely offered or available to women experiencing pregnancy loss. Reluctance to offer misoprostol or office uterine evacuation may come from attitudes and beliefs about treatment safety, beliefs about patient acceptance of these options, provider comfort with office procedures, or reimbursement concerns. Alternatively, environmental factors such as office space and staff comfort might also pose barriers to practice change. Fostering practice change requires a better understanding of provider barriers to adopting misoprostol and office uterine evacuations for EPF.
This study aims to describe health care provider knowledge, attitudes, and treatment preferences for EPF and to identify provider factors associated with misoprostol and office uterine evacuation use. We hypothesized that most providers do not routinely offer patients all effective treatment options. Our secondary hypothesis was that knowledge, attitudes, and perceived barriers to change are associated with sex, specialty, years in practice, and provider training.
Materials and Methods
We obtained approval for this study from the University of Michigan Institutional Review Board. We identified current EPF treatment practices using a cross-sectional survey of providers in the United States. Potential participants were randomly selected from membership lists of the American College of Obstetricians and Gynecologists, the American College of Nurse Midwives, and the American Academy of Family Physicians (FPs). After accounting for the proportion of providers practicing obstetrics and nonresponse rates, we mailed 3591 surveys to enroll 300 providers from each specialty. We used repeat mailings, limited the survey length, and provided a small financial incentive ($2.00) to encourage response. Questionnaires were initially mailed in January 2008, and 2 follow-up mailings were sent to nonresponders from March through June 2008. Providers were excluded if they were not practicing in one of the targeted specialties, or had not evaluated or treated anyone with EPF in the past 6 months.
We developed questionnaire items by consensus and a literature review. We drew heavily from previous work on provider behavior change and adherence to evidence-based practices. To assure the questionnaire was applicable to targeted provider types, an interdisciplinary group of investigators contributed to its development. Survey items addressed several areas including: (1) provider and practice characteristics such as age, sex, and practice setting; (2) use of office procedures in general; (3) current treatment practices for EPF; (4) knowledge and attitudes about different treatment options; and (5) barriers to adopting misoprostol use and office uterine evacuations.
The survey consisted of 3 types of questions. Closed ended/forced choice questions were used to elicit practice patterns, experience with office procedures, and provider knowledge of different treatment options. Ranking (1 = most preferred, 4 = least preferred) was used to assess provider treatment preferences and provider perception of patient treatment preferences. Level of agreement with a series of statements was used to assess attitudes and beliefs about the different treatment options, and perceived barriers to adopting misoprostol and office uterine evacuations. The questionnaire was pretested among physicians and midwives employed at the University of Michigan Health System. The survey was amended for clarity and length as needed.
We planned to enroll 300 providers from each specialty for a total of 900 respondents. With a sample size of 900, or 300 in each subgroup, we would have 90% power to detect a 10% difference in the proportion of providers that use a particular treatment option. Descriptive statistics were used to describe our sample population with regard to age, sex, years of practice, and specialty. Overall treatment patterns were compared initially between specialties. Using Pearson χ 2 and t tests, our initial analyses focused on testing for differences in knowledge, attitudes, barriers, and treatment patterns among groups of respondents defined by independent variables like practice specialty, years in practice, and practice setting (eg, university hospital or private practice). Since misoprostol and office uterine evacuations were the least commonly used treatment options, we focused our multivariate analysis on identifying factors associated with using these treatment modalities. We used logistic regression to identify which provider characteristics and attitudes were associated with misoprostol and office uterine evacuation use over the past 6 months. Prior to bivariate testing, we planned to include provider sex, specialty, and prior abortion training in the model since we expected these factors to be associated with practices. We used bivariate testing to identify other covariates significantly ( P < .05) associated with use of misoprostol or office uterine evacuation to include in the model. Finally, attitudes specific to misoprostol use and those specific to office uterine evacuation use were included in their respective regression models. Data were analyzed with software (SPSS 16.0; SPSS Inc, Chicago, IL).
Results
In total, 2040 out of 3591 contacted participants responded to our mailings for an overall response rate of 56.8%. Within each specialty, responses rates were 51.1%, 70.9%, and 53.5% for obstetrician-gynecologists (ob/gyns), certified nurse midwives/certified midwives (CNMs/CMs), and FPs. Of these, 1040 were excluded because they had not evaluated or treated a patient for EPF in the past 6 months. An additional 24 respondents were excluded because they were not employed as one of our targeted practitioner groups. This process left 976 respondents eligible for further analysis.
Table 1 presents the demographic and practice characteristics of our study population. Participants were predominately white, between 14-18 years since completing training, and currently practicing in a single-specialty practice setting. Almost all ob/gyns identified at least 1 office procedure performed in their practice but only 21.7% reported offering office uterine evacuations. FPs were least likely to offer any of the listed office procedures.
| Characteristic | Provider type | |||
|---|---|---|---|---|
| Obstetrician-gynecologist, (n = 309) | Certified nurse midwife/certified midwife, (n = 368) | Family medicine practitioner, (n = 299) | P value | |
| In practice, mean y (SD) a | 18.8 (9.21) | 14.3 (9.32) | 17.0 (9.02) | |
| Mean age, y (SD) | 50.9 (10.1) | 48.9 (10.5) | 49.2 (8.7) | |
| Provider sex, n (%) b | ||||
| Male | 161 (52.1) | 3 (0.8) | 166 (55.7) | < .001 |
| Female | 145 (46.9) | 360 (97.8) | 130 (43.6) | |
| Race/ethnicity, n (%) b | ||||
| White | 253 (81.9) | 350 (95.1) | 261 (87.9) | < .001 |
| Black | 12 (3.9) | 6 (1.6) | 9 (3.0) | |
| Native American | 0 | 1 (0.3) | 2 (0.7) | |
| Asian | 30 (9.7) | 2 (0.5) | 18 (4.7) | |
| Pacific Islander | 2 (0.6) | 0 | 0 | |
| Hispanic or Latino | 13 (4.2) | 8 (2.2) | 10 (3.4) | |
| County population, n (%) b | ||||
| <50,000 | 24 (7.8) | 41 (11.1) | 89 (29.8) | < .001 |
| 50,001-100,000 | 40 (12.9) | 57 (15.5) | 46 (15.4) | |
| 100,001-250,000 | 55 (17.8) | 76 (20.7) | 51 (17.1) | |
| 250,001-750,000 | 76 (24.6) | 72 (19.6) | 60 (20.1) | |
| >750,000 | 111 (35.9) | 106 (28.8) | 48 (16.1) | |
| Practice type, n (%) b | ||||
| University | 54 (17.5) | 49 (13.3) | 50 (16.7) | < .001 |
| Multispecialty | 34 (11.0) | 38 (10.3) | 54 (18.1) | |
| Single specialty | 193 (62.5) | 183 (49.7) | 134 (44.8) | |
| Other | 28 (9.1) | 98 (26.6) | 61 (20.4) | |
| Medicaid patients, n (%) b | ||||
| 0 | 53 (17.2) | 26 (7.1) | 30 (10.0) | < .001 |
| 1-25% | 151 (48.9) | 86 (23.4) | 166 (55.5) | |
| 26-50% | 63 (20.4) | 93 (25.3) | 77 (25.8) | |
| 51-75% | 32 (10.4) | 82 (22.3) | 15 (5.0) | |
| 76-100% | 9 (2.9) | 69 (18.8) | 8 (2.7) | |
| Office procedures offered, n (%) b | ||||
| None | 23 (7.4) | 64 (17.4) | 130 (43.5) | < .001 |
| IUC/IUD | 264 (85.4) | 269 (80.4) | 157 (52.5) | < .001 |
| LEEP | 194 (62.8) | 48 (13.0) | 32 (10.7) | < .001 |
| Hysteroscopy/Essure | 81 (26.2) | 15 (4.1) | 0 (0) | < .001 |
| Uterine evacuations/D&C | 67 (21.7) | 8 (2.2) | 18 (6.0) | < .001 |
| Endometrial ablation | 63 (20.4) | 11 (3.0) | 0 (0) | < .001 |
| No. with D&C privileges | 307 (99.4) | |||
| Any prior training in office uterine evacuations | 206 (67.3) | |||
| Prior induced abortion training | 61 (19.9) | |||
a Continuous variables compared using t test;
Table 2 presents the reported treatment patterns among the 3 specialties. These patterns reflect how patients were ultimately managed and does not necessarily indicate that the respondent themselves provided the service. As expected, practices differed significantly between provider specialties. For instance, ob/gyns were much less likely than other providers to report that their patients were managed expectantly (12.3% vs 36.3%, respectively; P < .001). Misoprostol use was most commonly reported among ob/gyns ( P < .001) but only 19.3% of ob/gyns reported that >25% of their patients were treated with misoprostol. In fact, most providers had not used misoprostol at all in the past 6 months for EPF treatment. Similarly, office uterine evacuations were uncommon among all groups, even ob/gyns. Only 16.2% reported ever using office evacuations to treat EPF in the past 6 months. Finally, referrals were also an important feature of services: 32.7% of CNMs/CMs and 37.4% of FPs reported referring >25% of patients to specialists for EPF treatment.
