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Objective: To compare the practice productivity of female and male obstetrician-gynecologists in Washington State., Methods: The primary data collection tool was a practice survey that accompanied each licensed practitioner's license renewal in 1998-1999. Washington State birth certificate data were linked with the licensure data to obtain objective information regarding obstetric births., Results: Of the 541 obstetrician-gynecologists identified, two thirds were men and one third were women. Women were significantly younger than men (mean age 43.3 years versus 51.7 years). Ten practice variables were evaluated: total weeks worked per year, total professional hours per week, direct patient care hours per week, nondirect patient care hours per week, outpatient visits per week, inpatient visits per week, percent practicing obstetrics, number of obstetrical deliveries per year, percentage working less than 32 hours per week, and percentage working 60 or more hours per week. Of these, only 2 variables showed significant differences: inpatient visits per week (women 10.1 per week, men 12.8 per week, P < or =.01) and working 60 or more hours per week (women 22.1% versus men 31.5%, P < or =.05). After controlling for age, analysis of covariance and multiple logistic regression confirmed these findings and in addition showed that women worked 4.1 fewer hours per week than men (P <.01). When examining the ratio of female-to-male practice productivity in 10-year age increments from the 30-39 through the 50-59 age groups, a pattern emerged suggesting lower productivity in many variables in the women in the 40-49 age group., Conclusion: Only small differences in practice productivity between men and women were demonstrated in a survey of nearly all obstetrician-gynecologists in Washington State. Changing demographics and behaviors of the obstetrician-gynecologist workforce will require ongoing longitudinal studies to confirm these findings and determine whether they are generalizable to the rest of the United States., Level of Evidence: II-3

Objective: To study risk factors in a large population of women over a broad geographic area as they entered obstetric care, and to assess how they distributed themselves among the specialties., Methods: Data from 1 year were gathered through a retrospective chart review of all women initiating care with randomly selected urban and rural obstetricians, urban and rural family physicians, and urban certified nurse midwives., Results: The majority of women had at least one risk factor at entry into care. When a scoring system was applied to the data, 13.5% of the women were designated "high risk," which is consistent with findings of other studies. However, women did not distribute themselves to provider types according to risk. Higher-risk women were more likely to choose family physicians, especially in rural areas. Much of this difference can be attributed to young maternal age, late entry into care, and lack of health insurance or Medicaid sponsorship., Conclusion: These findings suggest that economics and geography are more likely to influence a woman's initial choice of provider than medical and obstetric risk.

Objective: To examine the extent to which obstetric providers abide by prenatal practice guidelines published by ACOG., Methods: The prenatal records were abstracted for low-risk patients initiating care with randomly selected urban obstetrician-gynecologists, rural obstetrician-gynecologists, urban family physicians, rural family physicians, and urban certified nurse-midwives in Washington state between September 1, 1988 and August 30, 1989. The prenatal care recorded in their medical charts was compared with the ACOG-recommended guidelines., Results: Overall, providers of all five types adhered closely to the published standards. Certified nurse-midwives recorded a standard of practice that most closely matched that recommended by ACOG. Overall, there was less complete adherence in the recording of maternal height, fetal activity after 30 weeks' gestation, and fetal presentation at or after 36 weeks' gestation. Those laboratory tests that ACOG has recommended most recently (serum alpha-fetoprotein and diabetes screening) and those not recommended for routine use were ordered less often on average by providers., Conclusions: The cross-sectional nature of this study cannot demonstrate definitively that ACOG's guidelines have changed provider prenatal practices. However, these findings demonstrate that providers in varying specialties and geographic locations can adhere to a detailed set of clinical guidelines if they are appropriately disseminated and implemented.

This study compared the demographic and practice characteristics of physicians with and without obstetric malpractice experience. The sample consisted of 387 family physicians and 204 obstetricians in Washington state who were insured for obstetrics by a major malpractice carrier between January 1982 and June 1988. Fifty-three physicians (9%) had an obstetric malpractice claim during the study period. The approximate overall rate of obstetric malpractice claims was low: 0.32 per 1000 deliveries. The higher the total delivery volume (exposure), the greater the chance of having malpractice experience. Although physicians with practices of over 200 deliveries per year were more likely to have had malpractice experience, their risk of malpractice experience per delivery was lower than that of providers doing fewer than 200 deliveries per year. Our work suggests that insurers might consider basing obstetric malpractice premiums on numbers of deliveries rather than specialty.

We surveyed all potential obstetric providers in Washington state in the spring of 1989 to determine whether the passage of tort reform in 1986 had improved access to care for rural and medically indigent women. We found that, although the exodus of family physicians from obstetric practice that had been observed between 1985-1986 appears to have slowed, there is still substantial net attrition among family physicians. As a result, rural patients are having increasing difficulty obtaining local access to obstetric care. By contrast, the supply of obstetricians and midwives seems to be stable. All three groups of providers are increasingly reluctant to provide care to the growing number of Medicaid patients. Although tort reform may have slowed the rate at which providers are quitting obstetrics, equilibrium has not yet been achieved. Shortages of rural physicians and inadequate Medicaid reimbursement rates must be addressed to improve obstetric access for underserved groups.

We studied all physicians who purchased obstetric malpractice insurance from the Washington State Physicians Insurance Exchange and Association between January 1, 1982 and July 1, 1988. Of the 690 physicians studied, 171 (32% of the family physicians and 10% of the obstetricians) discontinued obstetrics but remained in practice. Physicians who discontinued obstetric practice were older, more likely to practice in an urban area, and more likely to be in solo practice than those who did not. Obstetricians who discontinued obstetric practice had a higher rate of new obstetric malpractice claims than did those who did not quit practicing obstetrics--14.5 versus 6.2 claims per 100 physician-years of coverage. By contrast, those family physicians leaving obstetrics had a lower rate of new claims than their peers who did not quit. We conclude that older physicians--particularly those in urban and solo practice--are most likely to stop practicing obstetrics, regardless of specialty. In addition, being named as the target of an obstetric malpractice claim plays a significant role in the decision of some obstetricians to discontinue obstetric practice.