Objective
The objective of the study was to examine the relationship between induced abortion training and views toward, and use of, office uterine evacuation and misoprostol in early pregnancy failure (EPF) care.
Study Design
We surveyed 308 obstetrician-gynecologists on their knowledge and attitudes toward treatment options for EPF and previous training in office-based uterine evacuation.
Results
Sixty-seven percent of respondents reported training in office uterine evacuation, and 20.3% reported induced abortion training. Induced abortion training was associated with strongly positive views toward both office-based uterine evacuation and misoprostol as treatment for EPF compared with those with office uterine evacuation training in other settings (odds ratio [OR], 2.64; P < .004 and OR, 3.22; P < .003, respectively). Furthermore, induced abortion training was associated with the use of office uterine evacuation for EPF treatment compared with those with office evacuation training in other settings (OR, 2.90; P = .004).
Conclusion
Training experiences, especially induced abortion training, are associated with the use of office uterine evacuation for EPF.
Early pregnancy failure (EPF) is one of the most common clinical scenarios encountered by practicing obstetrician-gynecologists. The term early pregnancy failure refers to an embryonic or fetal demise of an intrauterine pregnancy in the first trimester, including anembryonic gestation. Evidence-based treatment options include expectant management, treatment with misoprostol, and surgical uterine evacuation in an office or an operating room setting, although expectant and operating room surgical management dominate practice in the United States.
It appears that many women accept, and sometimes prefer, treatment with office uterine evacuation or misoprostol after EPF. Provider- and/or health service–related barriers may contribute to the fact that few health care providers appear to routinely offer these options. A lack of training is often cited by providers as a reason not to adopt new practices and may be an important modifiable barrier to offering office uterine evacuation for EPF.
Training to competency during residency is one way to ensure practicing physicians have specific skills. Office uterine evacuation and misoprostol are frequently used in induced abortion training but not often for other indications. The primary objective of this study was to examine the relationship between induced abortion training and views toward, and use of, office uterine evacuation and misoprostol in EPF care.
We hypothesized that physicians with previous induced abortion training would be more likely to have more favorable views toward office uterine evacuation and misoprostol as EPF treatment and to be more likely to use uterine evacuation and misoprostol for EFP treatment than those without induced abortion training.
Materials and Methods
We conducted a subanalysis of data collected for a larger, national study of EPF treatment patterns. In that study, current EPF treatment practices were identified using a cross-sectional survey of providers in the United States. Potential participants were randomly selected from the membership list of the American Congress of Obstetricians and Gynecologists, the American College of Nurse Midwives, and the American Academy of Family Physicians. We mailed 3591 surveys to enroll 300 providers from each specialty.
Details on our study methodology have been published previously. This analysis was limited to participating obstetrician-gynecologists who provided information on previous training experiences and reported managing EPF in the 6 months prior to study enrollment. We obtained approval for this study from the University of Michigan Institutional Review Board.
Questionnaire items were developed by a literature review and consensus. We drew heavily from previous work on provider behavior change and adherence to evidence-based practices. Survey items addressed several areas, including the following: (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 EPF treatment options; (5) barriers to adopting office uterine evacuation and misoprostol; and (6) previous training.
Previous training in office-based uterine evacuation was ascertained from responses to a single item asking respondents to identify in which context, if any, they gained experience with office uterine evacuation. Possible answers included: none, during residency training, postgraduate courses, induced abortion training, or other experience. Multiple responses were allowed.
Respondent attitudes and beliefs toward office uterine evacuation and misoprostol as EPF treatment were measured using the level of agreement with a series of statements. A summary score representing favorable views of office uterine evacuation was created from 7 items (Cronbach’s alpha of 0.81). Each item was measured on a 5-point scale, with 5 being the most favorable and 1 being the least favorable view. The minimum and maximum possible scores were 7 and 35, respectively. Similarly, a summary score representing favorable views of misoprostol use for EPF was created from 6 items (Cronbach’s alpha of 0.75). The minimum and maximum possible scores were 6 and 30, respectively. After examining the distribution of scores, participants scoring in the top 25th percentile were defined as strongly positive toward treatment type.
Descriptive statistics were used to describe our sample population with regard to age, sex, and years of practice. Overall treatment patterns and attitudes toward office uterine evacuation and misoprostol as EPF treatment were compared among the following: (1) those reporting no prior office uterine evacuation training, (2) those with any office uterine evacuation training, and (3) those specifically reporting induced abortion training. Using Pearson’s χ 2 and Student t tests, our initial analyses focused on testing for differences in knowledge, attitudes, barriers, and treatment patterns between these groups of respondents.
Logistic regression was used to examine the relationships between training and having strongly positive views toward office uterine evacuation or misoprostol for EPF and use of office uterine evacuation or misoprostol in the past 6 months. For each dependent variable, initially we examined its association with any type of training (vs no training) among all respondents. Next, to estimate the relative importance of induced abortion training vs office evacuation training in other settings, we limited our analysis to participants with any previous training. Prior to bivariate testing, we planned to include provider sex, years in practice, and practice type in the models. Additional covariates were identified during bivariate testing and were included if a significant relationship was identified ( P < .05) Data were analyzed with SPSS 17. (SPSS Inc, Chicago, IL).
Results
In total, 308 eligible obstetrician-gynecologists returned completed surveys, for a response rate of 51.1%. Three hundred two respondents provided information of previous training experiences and reported managing EPF in the past 6 months. Sixty-seven percent of respondents reported training in office-based uterine evacuation, but only 61 of respondents (20.0%) reported previous training in induced abortion techniques. Respondent characteristics are presented in Table 1 .
| Characteristic | All respondents (n = 302) | Any training in office uterine evacuation | Induced abortion training | ||||
|---|---|---|---|---|---|---|---|
| Yes (n = 204) | No (n = 98) | P value | Yes (n = 61) | No (n = 241) | P value | ||
| Mean years in practice (SD) a | 18.7 (9.2) | 18.9 (9.1) | 18.1 (9.5) | NS | 19.8 (9.7) | 18.4 (9.0) | NS |
| Provider sex, n (%) b | |||||||
| Male | 158 (51.8) | 115 (57.2) | 43 (43.9) | .04 | 30 (49.2) | 128 (53.1) | NS |
| Female | 144 (47.2) | 86 (42.8) | 55 (56.1) | 30 (49.2) | 111 (46.0) | ||
| Race/ethnicity, n (%) b | |||||||
| White | 251 (82.3) | 175 (85.8) | 75 (76.5) | NS | 55 (90.2) | 195 (80.9) | NS |
| County population, n (%) b | |||||||
| <50,000 | 23 (7.5) | 17 (8.3) | 6 (6.1) | NS | 5 (8.2) | 18 (7.5) | NS |
| 50,001-100,000 | 40 (13.1) | 28 (13.7) | 12 (12.2) | 5 (8.2) | 35 (14.5) | ||
| 100,001-250,000 | 55 (18.0) | 35 (17.2) | 19 (19.4) | 10 (16.4) | 44 (18.3) | ||
| 250,001-750,000 | 76 (24.9) | 49 (24.0) | 27 (27.6) | 16 (26.2) | 60 (24.9) | ||
| 750,000 | 108 (35.4) | 74 (36.3) | 32 (32.7) | 25 (41.0) | 81 (33.6) | ||
| Practice type, n (%) b | |||||||
| University | 52 (17.2) | 33 (16.2) | 19 (19.4) | NS | 13 (21.3) | 39 (16.2) | NS |
| Multispecialty | 34 (11.3) | 24 (11.8) | 9 (9.2) | 5 (8.2) | 28 (11.6) | ||
| Single specialty | 191 (63.2) | 126 (61.8) | 63 (64.3) | 38 (62.3) | 151 (62.7) | ||
| Other | 25 (8.3) | 21 (10.3) | 7 (7.1) | 5 (8.2) | 23 (9.5) | ||
| Medicaid patients, n (%) b | |||||||
| 0 | 51 (16.9) | 39 (19.8) | 12 (12.2) | NS | 14 (23.0) | 37 (15.4) | NS |
| 1-25 | 149 (49.3) | 106 (52.0) | 43 (43.9) | 33 (54.1) | 116 (48.1) | ||
| 26-50 | 63 (20.9) | 38 (18.6) | 25 (25.5) | 11 (18.0) | 52 (21.3) | ||
| 51-75 | 31 (10.3) | 17 (8.3) | 14 (14.3) | 2 (3.3) | 29 (12.0) | ||
| 76-100 | 8 (2.6) | 4 (2.0) | 3 (3.1) | 1 (1.6) | 6 (2.5) | ||
| Office procedures offered, n (%) b | |||||||
| None | 23 (7.5) | 13 (6.4) | 10 (10.2) | NS | 1 (1.6) | 22 (9.1) | NS |
| Intrauterine device placement | 260 (85.2) | 176 (86.3) | 82 (83.7) | NS | 58 (95.1) | 200 (83.0) | < .009 |
| Hysteroscopy/essure | 80 (26.2) | 60 (29.4) | 20 (20.4) | NS | 20 (32.8) | 60 (24.9) | NS |
| Uterine evacuations/D&C | 66 (21.6) | 63 (30.9) | 3 (3.1) | < .001 | 28 (45.9) | 38 (15.8) | < .001 |
| Endometrial ablation | 62 (20.3) | 42 (20.6) | 20 (20.4) | NS | 13 (21.3) | 49 (20.3) | NS |
| LEEP | 191 (62.6) | 133 (65.2) | 57 (58.2) | NS | 47 (77.0) | 143 (59.3) | < .006 |
| Context of office uterine evacuation training b | |||||||
| None | 98 (32.1) | ||||||
| Residency | 153 (50.2) | ||||||
| Induced abortion | 61 (20.0) | ||||||
| Postgraduate course/ experience | 23 (7.5) | ||||||
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
