Practice patterns during the third stage of labor: the effect of physician age and specialty.
METHODS. Using a mailed questionnaire, we surveyed all 178 Iowa obstetrician-gynecologists and a random sample of 163 Iowa family physicians to determine their practice patterns related to selected aspects of the third stage of labor. The data were analyzed using odds ratios and multiple logistic regression.
RESULTS. The analysis was based on answers from 302 physicians. Physicians in the oldest age quartile were three times more likely than physicians in the youngest age quartile to routinely explore the uterus after a vaginal delivery (P<.01). After controlling for specialty, younger physicians were more likely to believe that manual removal of the placenta is a risk factor for endometritis (adjusted odds ratio [OR] 0.7 for each l O@year increase in age, 95% confidence interval [Cl] 0.6 to 1.0). Controlling for age, family physicians were more likely than obstetrician-gynecologists to routinely order prophylactic antibiotics after manually removing the placenta (adjusted OR 2.0, 95% Cl 1.1 to 3.7).
CONCLUSIONS. Both physician age and specialty were associated with selected practice patterns involving the third stage of labor. Older physicians were less likely to believe that manually removing a placenta increases the risk of postpartum endometritis, and they were more likely to routinely explore the uterus after a vaginal delivery.
KEY WORDS. Labor stage, third; physician's practice patterns@ physicians, family@ obstetrics. CJ Fam Pract lqff,.
Obstetricians have debated the risks and benefits of elective manual removal of the placenta and routine uterine exploration after vaginal delivery.[1-3] In the preantibiotic era, these procedures were associated with high rates of infectious morbidity, which often approached 50%.[4,5] After the introduction of antibiotics, several investigators recommended routine exploration of the uterus to remove unsuspected retained placental fragments, thereby reducing the risk of postpartum hemorrhage.[6-9] Large uncontrolled patient series in the 1950s appeared to document the safety of this procedure.[7-9]
Manual removal of the placenta was also thought to be a safe procedure. A recent study, however, reported that manual removal of the placenta is a risk factor for postpartum endometritis. Before this study was published, we surveyed Iowa family physicians and obstetrician-gynecologists to determine their self-reported practice patterns for selected aspects of the third stage of labor. Many studies have found that family physicians use fewer interventions than obstetrician-gynecologists.[12-18] Most of these studies did not control for physician age, however, which is often an important predictor of practice patterns.[19,20] The purpose of the present study was to explore the effect of age and specialty on practice patterns related to the third stage of labor.
In June 1993, we mailed questionnaires to all 178 Iowa obstetrician-gynecologists and a random sample of 163 Iowa family physicians who practiced obstetrics. Potential participants were identified using a physician database that is maintained by the University of Iowa This database includes the physician's birth date, sex, specialty, and type of training (allopathic vs osteopathic). Physicians were eligible for the study if their self-identified specialty was family practice or obstetrics-gynecology. We excluded retired physicians and physicians in training, and we excluded family physicians who did not practice obstetrics. To identify family physicians who practiced obstetrics, we telephoned their office receptionists. After calling the receptionists of 430 physicians in random order, we identified 163 who practiced obstetrics.
The survey instrument consisted of five questions that explored beliefs and practice patterns related to the third stage of labor: (1) Is manual removal of a placenta a risk factor for the development of post-partum endometritis? (2) Do you routinely give prophylactic antibiotics after manually removing a placenta? (3) Do you selectively give prophylactic antibiotics after manually removing a placenta? (4) Do you routinely explore the uterus after spontaneous expulsion of the placenta? (5) Do you routinely remove the placenta manually (hand inside the uterus) after all vaginal deliveries?
The responses of family physicians were compared with those of obstetrician-gynecologists using the chi-square statistic. Physician age groups were compared using the chi-square test for trend.[21,22] We explored independent associations using multiple logistic regression.
The response rate for the obstetrician-gynecologists was 91% (162 of 178), and for family physicians, the response rate was 93% (151 of 163). Eleven obstetrician-gynecologist respondents were subsequently excluded because they returned blank questionnaires with notes stating that they no longer practiced obstetrics. Therefore, the final sample included 151 obstetrician-gynecologists and 151 family physicians. The obstetricians were older, on average, than the family physicians (45.6 +/- 9.9 years vs years, P=.02). Female physicians comprised 17% of all respondents, and 14% of respondents were osteopathic physicians.
Of the 302 respondents, 217 (72%) said that manual removal of the placenta is a risk factor for post-partum endometritis. Only 54 (18%) said that they routinely give prophylactic antibiotics after manually removing the placenta. Among physicians who did not give antibiotics routinely, 140 (57%) said they give antibiotics selectively. Forty-seven physicians (16%) said that they routinely explore the uterus after spontaneous expulsion of the placenta. None of the respondents said that they routinely perform manual removal of the placenta.
Physicians in the youngest age quartile (30 to 37 years; were 40% more likely than physicians in the oldest age quartile (50 to 83 years) to believe that manual removal of the placenta increases the risk of postpartum endometritis (P<.01). Physicians in the oldest age quartile were three times more likely than physicians in the youngest age quartile to explore the uterus after spontaneous expulsion of the placenta (P<.01). Physician age did not predict the routine use of prophylactic antibiotics after manually removing a placenta. Among physicians who did not give routine antibiotics, however, physicians in the youngest age quartile were 34% more likely than physicians in the oldest age quartile to selectively use prophylactic antibiotics (P<.01).
Obstetrician-gynecologists were less likely than family physicians to believe that manual placental removal is a risk factor for endometritis (P=.05). Obstetrician-gynecologists were less likely to give prophylactic antibiotics routinely (P=.04). and more likely to give them selectively (P=.05). They tended to routinely explore the uterus more often than family physicians did (P=.09).
Because both specialty and physician age were associated with beliefs and practice patterns, we used multiple logistic regression to identify independent associations. We found that younger physicians were more likely to believe that manual removal of the placenta is a risk factor for endometritis, but after controlling for age, physician specialty did not reach statistical significance Table). Using similar logistic models, we found that, after controlling for physician age, family physicians were more likely than obstetricians to use antibiotics routinely after manually removing the placenta. Among physicians who did not use antibiotics routinely, both young physician age and the obstetrics specialty were independently associated with selective antibiotic use. Finally, we found that older physicians were more likely to routinely explore the uterus, but after controlling for age, obstetricians were not more likely than family physicians to explore the uterus. There were no significant differences in beliefs or practice patterns between male and female physicians or between osteopathic and allopathic physicians.
[TABULAR DATA OMITTED]
In this study, physician age was an important predictor of practice patterns related to the third stage of labor. Older physicians were less likely to believe that manual removal of the placenta increases the endometritis risk, and they were more likely to routinely explore the uterus.
Our findings are consistent with other studies that found strong associations between physician age and practice patterns.[19,20] For example, in a Canadian study, both older physicians and family physicians were less likely to perform vaginal delivery after cesarean delivery; however, a multivariate analysis determined that older physician age, but not specially, independently predicted lower rates of vaginal birth after cesarean delivery.
We can only speculate about the underlying causes for the age differences we found. Older physicians may have difficulty staying current with advances in medicine, or they may feel more comfortable practicing as they were trained, or they may have altered their practice based on memorable occurrences. Although many studies found lower levels of knowledge and compliance with guidelines among older physicians,[19,23-25] others found no association with age[27-29] or even the opposite trend.[30,31]
Family physicians are less likely than obstetricians to use labor induction, epidural analgesia, and forceps delivery.[12-18] In spite of these differing practice patterns, patient outcomes do not vary between the two specialties.[12-18] In these studies, the investigators controlled for differences in patient characteristics, but usually not physician characteristics, such as age or other demographic variables.
In an attempt to explain the age differences in this study, we reviewed the last 10 editions of Williams Obstetrics, a standard obstetrics textbook.[2,32-40] In the 1950 edition, the editors recommended waiting 60 minutes before manually removing a retained placenta. By 1956, the recommendation was to wait only 30 minutes, and by 1966, only 5 minutes. Since 1985, no specific time guidelines have been included in the text. The practice differences we found were better explained by assertions in the journal literature[6-9] than by changes in textbook recommendations.
Our findings should be interpreted cautiously because we studied only Iowa physicians, and the extent to which our findings can be generalized to others is unknown. We analyzed a small number of explanatory variables, and other physician characteristics or practice settings might have helped explain the differences we found. We surveyed only family physicians who practiced obstetrics, but we surveyed all obstetrician-gynecologists. This discrepancy could have partially explained the difference in mean age between the two specialties. However, the discrepancy does not explain the age or specialty differences we found because both variables were included in the midtivariate analysis. Finally, our data consist of self-reports, which may vary from actual practice.
Family physicians' practice patterns are often compared with the practice patterns of other specialties.[12-20,41-42] Both specialty and physician age should be included in these analyses because both variables may independently predict beliefs and practices, and because these variables may be confounders for each other in populations where physician age varies by specialty.
This study was supported by the University of Iowa Research Development Fund, grant No. 2310017.
[1.] Epperly TD, Fogarty JP, Hodges SG. Efficacy of routine post-partum uterine exploration and manual sponge curettage. J Fam Pract 1989; 28:172-6. [2.] Cunningham FG, MacDonald PC, Gant NF, Leveno KJ, Gilstrap LC III. Williams obstetrics. 19th ed. Norwalk, Conn: Appleton & Lange, 1993. [3.] Gabbe SG, Niebyl JR, Simpson JL Obstetrics: normal and problem pregnancies. 2nd ed. New York, NY: Churchill Livingstone, 1991. [4.] Thomas WO Jr. Present-day concepts of manual removal of the placenta. West J Surg Obstet Gynecol 1955; 63:129-45. [5.] Peckham CH. A statistical survey of 186 cases of manual removal of the placenta. Bull Johns Hopkins Hosp 1935; 56:224-35. [6.] Duckman S, Dennen P. Manual exploration of the postpartum uterus. Obstet Gynecol 1955; 5:628-33. [7.] Herman L, Ward C, Snyder D. Postpartum manual intrauterine examination. Am J Obstet Gynecol 1955; 69:185-90. [8.] Hawkins RJ. Exploration of the uterus following delivery. Am J Obstet Gynecol 1955; 69:1094-102. [9.] Mozley PD. A study of 3022 routine manual explorations of the postparturn uterus. Am J Obstet Gynecol 1958; 75:1126-7. [10.] Thomas WO Jr. Manual removal of the placenta. Am J Obstet Gynecol 1963; 86:600-6. [11.] Ely JW, Rijhsinghani A, Bowdler NC, Dawson JD. The association between manual removal of the placenta and postpartum endometritis following vaginal delivery. Obstet Gynecol [12.] Reid AJ, Carroll JC, Ruderman J, Murray MA. Differences in intrapartum obstetric care provided to women at low risk by family physicians and obstetricians. Can Med Assoc J 1989; 140:625-33. [13.] Klein M, Lloyd I, Redman C, Bull M, Turnbull AC. A comparison of low-risk pregnant women booked for delivery in two systems of care: shared care (consultant) and integrated general practice unit. I. Obstetrical procedures and neonatal outcome. Br J Obstet Gynaecol 1983; 90:118-22, 123-8. [14.] Klein M, Lloyd l, Redmana C, Bull M, Turnbull AC. A comparison of low-risk pregnant women booked for delivery in two systems of care: shared care (consultant) and integrated general practice unit. H. Labour and delivery management and neonatal outcome. Br J Obstet Gynaecol 1983; 90:123-8. [15.] Krikke EH, Bell NR. Relation of family physician or specialist care to obstetric interventions and outcomes in patients at low risk: a western Canadian cohort study. Can Med Assoc J 1989; 140:637-43. [16.] Phillips WR, Rice GA, Layton RH. Audit of obstetric care and outcome in family medicine, obstetrics, and general practice. J FaM Pract 1978; 6:1209-16. [17.] Rosenberg E, Klein M. Is maternity care different in family practice? A pilot matched pair study. J Fam Pract 1987; 25:238-42. [18.] Wanderer MJ, Suyehira JG. Obstetrical care in a prepaid cooperative: a comparison between family practice residents, family physicians, and obstetricians. J Fam Pract 1980; 11:601-6. [19.] Goldman G, Pineault R, Bilodeau H, Blais R. Effects of patient, physician and hospital characteristics on the likelihood of vaginal birth after previous cesarean section in Quebec. Can Med Assoc J 1990; 143:1017-24. [20.] Hlatky MA, Cotugno H, O'Connor C, Mark DB, Pryor DB, Califf RM. Adoption of thrombolytic therapy in the management of acute myocardial infarction. Am J Cardiol 1988; 61:510-14. [21.] Mantel N. Chi-square tests with one degree of freedom: extensions of the Mantel-Haenszel procedure. J Am Stat Assoc 1963; 58:690-700. [22.] Maclure M, Greenland S. Tests for trend and dose response: misinterpretations and alternatives. Am J Epidemiol 1992; 135:96-104. [23.] Kenny SJ, Smith PJ, Goldschmid MG, Newman JM, Herman WH. Survey of physician practice behaviors related to diabetes mellitus in the US. Physician adherence to consensus recommendations. Diabetes Care 1993; 16:1507-10. [24.] Stange KC, Fedirko T, Zyzanski SJ, Jaen CR. How do family physicians prioritize delivery of multiple preventive services? J Fam Pract 1994; 38:231-7. [25.] Schwartz JS, Lewis CE, Clancy C, Kinosian MS, Radany MH, Koplan JP. Internists' practices in health promotion and disease prevention. A survey. Ann Intern Med 1991; 114:46-53. [26.] Faber MM, Hoppe SK, Diehl AK. Physician knowledge and clinical behavior regarding automobile safety for children. Pediatrics 1985; 75:248-53. [27.] Walsh-Sukys MC, Cornell DJ, Houston LN, Keszler M, Kanto WP Jr. Treatment of persistent pulmonary hypertension of the newborn without hyperventilation: an assessment of diffusion of innovation. Pediatrics 1994; 94:303-6. [28.] Brook RH, Park RE, Chassin MR, Solomon DH, Keesey J, Kosecoff J. Predicting the appropriate use of carotid endarterectomy, upper gastrointestinal endoscopy, and coronary angiography. N Engl J Med 1990; 323:1173-7. [29.] Hartzema AG, Christensen DB. Nonmedical factors associated with the prescribing volume among family practitioners in an HMO. Med Care 1983; 21:990-1000. [30.] Lurie N, Slater J, McGovern P, Ekstrum J, Quam I, Margolis K Preventive care for women. Does the sex of the physician matter? N Engl J Med 1993; 329:478-82. [31.] Blanchard CG, Labrecque MS, Ruckdeschel JC, Blanchard EB. Physician behaviors, patient perceptions, and patient characteristics as predictors of satisfaction of hospitalized adult cancer patients. Cancer 1990; 65:186-92. [32.] Eastman NJ. Williams obstetrics. 10th ed. New York, NY: Appleton-Century-Crofts, 1950. [33.] Eastman NJ. Williams obstetrics. 11th ed. New York, NY: Appleton-Century-Crofts, 1956. [34.] Eastman NJ, Hellman LM. Williams obstetrics. 12th ed. New York, NY: Appleton-Century-Crofts, 1961. [35.] Eastman NJ, Hellman LM. Williams obstetrics. 13th ed. New York, NY: Appleton-Century-Crofts, 1966. [36.] Hellman LM, Pritchard JA. Williams obstetrics. 14th ed. New York, NY: Appleton-Century-Crofts, 1971. [37.] Pritchard JA, MacDonald PC. Williams obstetrics. 15th ed. New York, NY: Appleton-Century-Crofts, 1976. [38.] Pritchard JA, MacDonald PC. Williams obstetrics. 16th ed. New York, NY: Appleton-Century-Crofts, 1980. [39.] Pritchard JA, MacDonald PC, Gant NF. Williams obstetrics. 17th ed. Norwalk, Conn: Appleton-Century-Crofts, 1985. [40.] Cunningham FG, MacDonald PC, Grant NF Williams obstetrics. 18th ed. Norwalk, Conn: Appleton A Lange, 1989. [41.] Osborn EH, Bird JA, McPhee SJ, Rodnick JE, Fordham D. Cancer screening by primary care physicians. Can we explain the differences? J Fam Pract 1991; 32:465-71. [42.] Bergner M, Allison CJ, Diehr P, Ford LG, Feigl P. Early detection and control of cancer in clinical practice. Arch Intern Med 1990; 150:431-6.
|Printer friendly Cite/link Email Feedback|
|Author:||Ely, John W.; Howser, Donald M.; Dawson, Jeffrey D.; Bowdler, Noelle C.; Rijhsinghani, Asha|
|Publication:||Journal of Family Practice|
|Date:||Dec 1, 1996|
|Previous Article:||Osteoporosis: talk isn't cheap, it's essential.|
|Next Article:||Eradication of Helicobacter pylori among patients from a primary care practice.|