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Background: Professional societies such as the American College of Obstetricians and Gynecologists (ACOG) promote the idea that postpartum care is an ongoing process where there is adequate opportunity to provide services and support. Nonetheless, in practice, the guidelines ask clinicians to perform more clinical responsibilities than they might be able to do with limited time and resources., Methods: We conducted an online survey among practicing obstetric clinicians (obstetrician/gynecologists (OB/GYNs), midwives, and family medicine doctors) in California about their priorities and care practices for the first postpartum visit and explored how they prioritize multiple clinical responsibilities within existing time and resources. Between September 2023 and February 2024, 174 out of 229 eligible participants completed the survey, a 76% response rate. From a list of care components, we used descriptive statistics to identify those that were highly prioritized by most clinicians and those that were considered a priority by very few and examined the alignment between prioritized components and recommended care practices., Results: Clinicians were highly invested in the care components that they rated as most important, indicating that they always check these components or assess them when they perceive patient need. Depression and anxiety, breast health/breast feeding issues, vaginal birth complications and family planning counseling were highly ranked components by all clinicians. In contrast, clinicians more often did not assess those care components that infrequently ranked highly among the priority listing, consisting mainly of social drivers of health such as screening and counseling for intimate partner violence, working conditions and food/housing insecurity. In both instances, we found little discordance between priorities and care practices. However, OB/GYNs and midwives differed in some care components that they prioritized highly., Conclusions: While there is growing understanding of how important professional society recommendations are for maternal-infant health, clinicians face barriers completing all recommendations, especially those components related to social drivers of health. However, what the clinicians do prioritize highly, they are likely to perform. Now that Medi-Cal (Medicaid) insurance is available in California for up to 12 months postpartum, there is a need to understand what care clinicians provide and what gaps remain., (© 2024. The Author(s).)

Objective: The Nuchal Translucency Quality Review (NTQR) program has provided standardized education, credentialing and epidemiological monitoring of nuchal translucency (NT) measurements since 2005. Our aim was to review the effect on NT measurement of provider characteristics since the program's inception., Methods: We evaluated the distribution of NT measurements performed between January 2005 and December 2019, for each of the three primary performance indicators of NT measurement (NT median multiples of the median (MoM), SD of log 10 NT MoM and slope of NT with respect to crown-rump length (CRL)) for all providers within the NTQR program with more than 30 paired NT/CRL results. Provider characteristics explored as potential sources of variability included: number of NT ultrasound examinations performed annually (annual scan volume of the provider), duration of participation in the NTQR program, initial credentialing by an alternative pathway, provider type (physician vs sonographer) and number of NT-credentialed providers within the practice (size of practice). Each of these provider characteristics was evaluated for its effect on NT median MoM and geometric mean of the NT median MoM weighted for the number of ultrasound scans, and multiple regression was performed across all variables to control for potential confounders., Results: Of 5 216 663 NT measurements from 9340 providers at 3319 sites, the majority (75%) of providers had an NT median MoM within the acceptable range of 0.9-1.1 and 85.5% had NT median MoM not statistically significantly outside this range. Provider characteristics associated with measurement within the expected range of performance included higher volume of NT scans performed annually, practice at a site with larger numbers of other NT-credentialed providers, longer duration of participation in the NTQR program and alternative initial credentialing pathway., Conclusions: Annual scan volume, duration of participation in the NTQR program, alternative initial credentialing pathway and number of other NT-credentialed providers within the practice are all associated with outcome metrics indicating quality of performance. It is critical that providers participate in ongoing quality assessment of NT measurement to maintain consistency and precision. Ongoing assessment programs with continuous feedback and education are necessary to maintain quality care. © 2021 International Society of Ultrasound in Obstetrics and Gynecology., (© 2021 International Society of Ultrasound in Obstetrics and Gynecology.)

Introduction: the use of ultrasound is one of the most vital tools in the management of pregnancies and contributes significantly in improving maternal and child health. Certain indications in pregnancy, guide the obstetrician as to which obstetric scan deems appropriate. The full realization of the benefits of ultrasound depends on whether it is being used appropriately or not, and hence this study aimed at auditing for the appropriate indications for obstetric ultrasound., Methods: a review of all request forms for obstetric scan between June 2019 and July 2020 was performed to assess the appropriateness of requests for obstetric ultrasound at the Cape Coast Teaching Hospital. The data obtained was analyzed using SPSS (SPSS Inc. Chicago, IL version 20.0). A Chi-squared test of independence was used to check for statistically significant differences between variables at p ≤ 0.05., Results: three hundred and fourteen (314) out of the 527 request forms had clinical indications stated. 174 (81.7%) of requests from Cape Coast Teaching Hospital and 39 (18.3%) from other health centers did not indicate patients clinical history/indication on the request forms. Majority 76 (68.5%) of scans in the first trimester were done without indications/history. Only 29 of requests with clinical history were inappropriate., Conclusion: practitioners should be mindful of adequately completing request forms for obstetric investigations since a large number of practitioners do not state the history/indications for the scans. There should be continuous medical education on the importance of appropriate indication for obstetric ultrasound., Competing Interests: The authors declare no competing interests., (Copyright: Emmanuel Kobina Mesi Edzie et al.)

Background: Obesity is associated with the development of polycystic ovary syndrome (PCOS) and contributes substantially to metabolic abnormalities in women with PCOS. The study aimed to describe and compare the practices of physicians in the diagnosis, evaluation, and treatment of obesity in patients with PCOS., Methods: Reproductive endocrinologists (Repro-Endo) and obstetrician-gynecologists (non-reproductive medicine specialty, OB-Gyn) in China participated in a survey, and their responses were analyzed using χ 2 tests, Fisher exact tests, and multivariable logistic regression analysis., Results: The study analyzed 1318 survey responses (85.8% OB-Gyn; 97.3% women). Body mass index was the most common diagnostic criterion for obesity; only 1.3% of participants measured waist circumference to identify abdominal obesity. More Repro-Endo participants (25% of all participants) enquired about the psychological problems of patients with obesity than OB-Gyn participants, and 42.5% of participants reported ordering both a lipid profile and oral glucose tolerance test (OGTT) for patients with obesity and PCOS. Multivariable analysis, that included physician's specialty, age, hospital grade, and number of patients with PCOS seen annually, revealed that OB-Gyn participants were less likely to order OGTT (OR, 0.3; 95% CI, 0.2-0.4) and lipid profile (OR, 0.2; 95% CI, 0.1-0.3) than Repro-Endo participants. The most common treatments for patients with PCOS were lifestyle modification (> 95%) and metformin (> 80%). More Repro-Endo participants prescribed metformin at a dose of 1.5 g/day compared with OB-Gyn (47.6% vs. 26.3%), and more OB-Gyn participants reported being unclear about the appropriate dosage of metformin for patients with obesity and PCOS (8.9% vs. 1.6%)., Conclusion: Our survey identified knowledge gaps in metabolic screening for patients with obesity and PCOS and a disparity in the evaluation and treatment of obesity in PCOS among different specialties. Similarly, it highlights the need to improve obesity management education for physicians caring for women with PCOS., (© 2021. The Author(s).)

The aim of this study was to evaluate clinicians' views of managing women with first-trimester Recurrent Miscarriage within the UK compared with RCOG guidance. An online survey of 150 Association of Early Pregnancy Units members was conducted using SurveyMonkey™. Analysis was limited to UK-based respondents (102). Of the three key investigations, 98% performed antiphospholipid antibodies (APA) screening, 93.1% performed karyotyping for subsequent miscarriages and 86.3% performed a pelvic ultrasound routinely. Other routine investigations included inherited thrombophilias (65.7%), thyroid function tests (51.9%), diabetes mellitus screening (35.3%), parental karyotyping (34.3%), androgen profile (25.5%), 3-D ultrasound (17.6%), hysteroscopy (12.7%), hysterosalpingogram (9.8%), Vitamin D (7.8%), peripheral natural killer cells (2.9%) and uterine natural killer cells (2.9%). APA-positive women were offered treatment by 97.1%; however, 23.5% routinely offered treatment for APA-negative women. Other treatments offered routinely included progesterone (27.5%) and metformin (1.9%). Most clinicians managed RM as recommended by RCOG, however we have highlighted considerable deviation from the RCOG guidelines.IMPACT STATEMENT What is already known on this subject? Recurrent miscarriage (RM) can cause significant distress to women and their partners prompting referrals for investigation and management of this condition. Although UK national clinical guidance exists published by RCOG, the adherence to the guidance in clinical practice is not known. What do the results of this study add? This study shows that most clinicians performed investigations recommended by RCOG when managing women with RM. However, we have highlighted considerable variation of practice; many additional investigations were routinely performed and a quarter of clinicians offered treatments outside the RCOG guidance. What are the implications of these findings for clinical practice and/or further research? This paper demonstrates considerable variation of practice across the UK. Clinical practice may continue to vary whilst there are separate guidelines available from different professional organisations worldwide. Collaboration to produce a general consensus could reduce the variation in the care that these women receive.

Background: The period around childbirth and the first 24 hours postpartum remains a perilous time for both mother and newborn. Health care providers' compliance to the World Health Organization modified partogram across the active first stage of labor is a graphic representation of a mother's condition that is used as a guide in providing quality obstetrics care. However, little evidence is documented on the health providers' adherence to the use of the partograph in Ethiopia, which limits health care providers' ability to improve quality care services. Therefore, this study assessed the adherence of partograph use and associated factors in Ethiopia., Methods: Data from the Ethiopian 2016 National Emergency Obstetric and Newborn Care survey of 3,804 health facilities that provided maternity services were used. We extracted 2611 partograph charts over a 12 months period prior to the survey to review the proper recording of each component. Data analyses were performed using SPSS version 22.0 software. A logistic regression analyses was used to identify the association of explanatory variables with the outcome variable. A p-value of <0.05 was considered as cut off point to declare the significance association in the multivariable analysis., Results: Of the total 2611 partographs reviewed, 561(21.5%) of them were fully recorded as per the WHO guideline. Particularly, molding in 50%, color of liquor in 70.5%, fetal heart beat in 93.3%, cervical dilation in 89.6%, descent in 63.2%, uterine contraction in 94.5%, blood pressure in 80.5%, pulse rate in 70.5%, and temperature in 53% were accurately recorded. The odds of adherence to partograph use were 1.4 in rural health facilities when compared to their counterparts (AOR=1.44; 95% CI: 1.15, 1.80, P- 0.002)., Conclusion: This study revealed a poor level of adherence in partograph use in Ethiopia. Molding, maternal temperature and decent were the least recorded parameters of the partograph. The odds of completion of partograph were high in rural facilities. Strong supporting supervision and mentoring the health workers to better record and use of partograph are needed mainly in urban health facilities. Moreover in the future, interventional research should be conducted to improve the current rate of adherence.

Background: Breast cancer diagnosed during pregnancy (BCP) is uncommon, and thus there is limited evidence on its treatment. However, the incidence of BCP is increasing probably due to women having children at an older age. We aimed to clarify the practice patterns and limitations in treatment for BCP in Japan., Methods: A cross-sectional survey was developed for board-certified Japanese breast cancer specialists (n = 1583) to evaluate their knowledge, attitude, experience, and practice patterns regarding BCP. Survey items also included questions regarding potential barriers of practice toward patients diagnosed during pregnancy and respondents' background., Results: In March 2018, 492 (31.1%) breast oncologists responded to the survey. Among them, 234 (48%) respondents had the experience of treating at least one case of BCP. The accuracy of knowledge about BCP was evaluated by three items regarding BCP treatment from the latest Japanese Breast Cancer Society treatment guideline, and 265 (54%) were categorized to have "appropriate knowledge". Majority of the physicians (89%) have responded that patients should be treated in a center where both a cancer-treating team and obstetrician exist, and 48% responded that treating patients by the collaboration of cancer-treating team and obstetric team in different institutes is an alternative reasonable option., Conclusions: Interest, knowledge, and awareness of the guidelines appear to influence physician attitude, and thus it is urgently important to lay out educational materials and learning opportunities regarding BCP for breast specialists. A regional network of oncologists, obstetricians, and pediatricians to support the BCP patients should be developed.

Background: Antenatal corticosteroids (ANC) reduce mortality and morbidity in preterm babies, but prescription practices vary., Aims: To assess obstetricians' compliance with the recommendations of the Australian and New Zealand clinical practice guidelines on use of ANC., Materials and Methods: An anonymous online questionnaire was distributed to Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists., Results: All respondents reported prescribing an initial course of ANC according to the guidelines if preterm birth at 28 weeks' gestation was expected within 24 or 72 h. However, 22% reported prescribing ANC even if birth was not expected within seven days. This was reported more often by practitioners not using adjunct tests to predict preterm birth (14% vs 69%; P < 0.001). An initial course of ANC at ≥35 weeks was prescribed by 52% of respondents. However, 93% reported prescribing ANC at ≥35 weeks prior to elective caesarean section. Repeat courses of ANC were prescribed by 76% of respondents. Of these, 89% reported prescribing repeat courses beyond the guideline recommendations at ≥33 weeks and 29% exceeded the recommendations on number of repeat courses., Conclusions: For infants born at <35 weeks, current ANC prescribing patterns in Australia and New Zealand are consistent with the guideline recommendations and result in high rates of administration in this group. However, administration of ANC to groups where benefits have not been demonstrated is commonly reported. Adherence to the guideline recommendations would decrease ANC exposure to babies for whom there is no strong evidence of benefit., (© 2018 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Objectives: Management of rheumatic diseases (RD) is often problematic in pregnant patients, hence the need for guideline implementation. This survey-based study aimed to assess beliefs among obstetricians and rheumatologists about managing RD in pregnant Lebanese patients., Methods: Questionnaires were completed by a representative sample of rheumatologists and obstetricians practicing throughout Lebanon. Collected data included physicians' information, opinion on pregnancy in RD patients, compatible drugs with fertility, pregnancy and breastfeeding, references used in their clinical management, referral to specialists, and knowledge about guidelines. Qualitative variables were analysed using Chi-square or Fisher's exact tests, and quantitative variables using Wilcoxon or Student t-tests. Results were matched against a scoring system based on the EULAR/BSR guidelines. p-value <0.05 indicated statistical significance., Results: Analysis showed high response rates of physicians, especially among rheumatologists. Overall, physicians practice was in concordance with international guidelines and only few misconceptions were reported. Systemic lupus erythematosus (SLE) was associated with risk on fertility, foetal malformation and eclampsia while anti-phospholipid (APL) syndrome was associated with miscarriage and vasculitis with eclampsia. Spondyloarthritis was considered 'safe' in pregnancy. Most physicians think that cyclophosphamide, leflunomide, methotrexate, mycophenolate mofetil and azathioprine compromise fertility, pregnancy, and breastfeeding., Conclusions: Our data showed relatively good concordance of the physicians' beliefs with the current literature and recommendations. However, we identified misconceptions about anti-rheumatic drugs safety in pregnancy and discrepancy between rheumatologists and obstetricians practices; hence the need for promoting collaboration between both specialties and disseminating knowledge to physicians and patients in the Middle East region.

Background: Prenatal exposures have known adverse effects on maternal and neonatal outcomes. Professional societies recommend routine screening for environmental, occupational, and dietary exposures to reduce exposures and their associated sequelae., Objective: Our objective was to determine the frequency of environmental exposure screening by obstetricians and gynecologists (OBGYNs) at initial patient visits., Study Design: Practicing OBGYNs were approached at the University of Colorado and by social media. The survey instrument queried demographics, environmental literacy, and screening practices. Statistical analysis was performed using Chi-square and two-sample t-test., Results: We received 312 online survey responses (response rate of 12%). Responding OBGYNs were predominantly female (96%), board-certified (78%), generalists (65%) with a mean age of 37.1 years. Fewer than half of physicians screened for the following factors: occupational exposures, environmental chemicals, air pollution, pesticide use, personal care products, household cleaners, water source, use of plastics for food storage, and lead and mercury exposure. Eighty five percent of respondents reported that they did not feel comfortable obtaining an environmental history and 58% respondents reported that they performed no regular screening of environmental exposures. A higher frequency of screening was associated with > 4 years of practice (p = 0.001), and having read the environmental committee opinion (p = <0.001)., Conclusion: The majority of OBGYNs did not incorporate screening for known environmental exposures into routine practice. Reading the environmental committee opinions was strongly and significantly associated with a higher rate of screening. Improving physician comfort in counseling patients may enhance screening for exposures that affect reproductive health.

Objective The purpose of this study was to examine the content of the first prenatal visit within an academic medical center clinic and to compare the topics discussed to 2014 American College of Obstetrics and Gynecologists guidelines for the initial prenatal visit. Methods Clinical interactions were audio recorded and transcribed (n = 30). A content analysis was used to identify topics discussed during the initial prenatal visit. Topics discussed were then compared to the 2014 ACOG guidelines for adherence. Coded data was queried though the qualitative software and reviewed for accuracy and content. Results First prenatal visits included a physician, nurse practitioner, nurse midwife, medical assistant, medical students, or a combination of these providers. In general, topics that were covered in most visits and closely adhered to ACOG guidelines included vitamin supplementation, laboratory testing, flu vaccinations, and cervical cancer screening. Topics discussed less often included many components of the physical examination, education about pregnancy, and screening for an identification of psychosocial risk. Least number of topics covered included prenatal screening. Conclusions for Practice While the ACOG guidelines may include many components that are traditional in addition to those based on evidence, the guidelines were not closely followed in this study. Identifying new ways to disseminate information during the time constrained initial prenatal visit are needed to ensure improved patient outcomes.

Ovarian cancer is the second most common type of female reproductive cancer, and more women die from ovarian cancer than from cervical cancer and uterine cancer combined. Currently, there is no strategy for early detection of ovarian cancer that reduces ovarian cancer mortality. Taking a detailed personal and family history for breast, gynecologic, and colon cancer facilitates categorizing women based on their risk (average risk or high risk) of developing epithelial ovarian cancer. Women with a strong family history of ovarian, breast, or colon cancer may have hereditary breast and ovarian cancer syndrome (BRCA mutation) or hereditary nonpolyposis colorectal cancer (Lynch syndrome), and these women are at increased risk of developing ovarian cancer. Women with these conditions should be referred for formal genetic counseling to better assess their cancer risk, including their risk of ovarian cancer. If appropriate, these women may be offered additional testing for early detection of ovarian cancer. The use of transvaginal ultrasonography and tumor markers (such as cancer antigen 125), alone or in combination, for the early detection of ovarian cancer in average-risk women have not been proved to reduce mortality, and harms exist from invasive diagnostic testing (eg, surgery) resulting from false-positive test results. The patient and her obstetrician-gynecologist should maintain an appropriate level of suspicion when potentially relevant signs and symptoms of ovarian cancer are present.

Ovarian cancer is the second most common type of female reproductive cancer, and more women die from ovarian cancer than from cervical cancer and uterine cancer combined. Currently, there is no strategy for early detection of ovarian cancer that reduces ovarian cancer mortality. Taking a detailed personal and family history for breast, gynecologic, and colon cancer facilitates categorizing women based on their risk (average risk or high risk) of developing epithelial ovarian cancer. Women with a strong family history of ovarian, breast, or colon cancer may have hereditary breast and ovarian cancer syndrome (BRCA mutation) or hereditary nonpolyposis colorectal cancer (Lynch syndrome), and these women are at increased risk of developing ovarian cancer. Women with these conditions should be referred for formal genetic counseling to better assess their cancer risk, including their risk of ovarian cancer. If appropriate, these women may be offered additional testing for early detection of ovarian cancer. The use of transvaginal ultrasonography and tumor markers (such as cancer antigen 125), alone or in combination, for the early detection of ovarian cancer in average-risk women have not been proved to reduce mortality, and harms exist from invasive diagnostic testing (eg, surgery) resulting from false-positive test results. The patient and her obstetrician-gynecologist should maintain an appropriate level of suspicion when potentially relevant signs and symptoms of ovarian cancer are present.

Objectives: To assess the adhesion of French obstetricians and gynecologists to the French clinical practice guidelines for pregnancy loss, issued by the French College of Obstetricians and Gynecologists, one year after publication., Methods: An online vignette-based study was emailed to a sample of French obstetricians and gynecologists to compare their management of women with missed early miscarriage and incomplete early miscarriage. A descriptive statistical analysis was performed comparing the rates of appropriate management for these two indications before and after the release of the guidelines., Results: Of the 404 specialists contacted, 143 completed the questionnaire. Forty-three percent stated that they had changed their practices following the release of the guidelines. The rate of adhesion was moderate for the management of missed early miscarriage (53% after publication of the guidelines versus 42% before, P=0.001) with a trend to avoid watching-and-waiting management. The rate of adhesion was poor for the management of incomplete early miscarriage (43% after the publication of the guidelines versus 27% before, P<0.001) with a lower use of misoprostol., Conclusion: Adhesion to the French guidelines appears to be moderate for the management of missed early miscarriage and low for the management of incomplete early miscarriage., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Purpose: Many international guidelines recommend induction of labour beyond 41 weeks to reduce perinatal morbidity and mortality. In 2010, a new German guideline with this recommendation was published. The aim of this study was to investigate whether this recommendation influenced clinical outcome., Material and Methods: All cases with induction of labour beyond 40 weeks in 2008, 2009, 2011 and 2012 were examined. Multiple pregnancy and Caesarean section in the case history were exclusion criteria. The years before publication of the new German guideline (2008 and 2009) were compared with those afterwards (2011 and 2012) with regard to several outcome parameters like rate of labour induction, efficacy of induction of labour and foetal outcome., Results: After publication of the guideline there were more inductions of labour undertaken (300 [11.2%] vs. 472 [15.4%], p<0.0001) with less pregnancies beyond 42 weeks (9 [3%] vs. 5 [1%], p=0.0489). However, there was no difference concerning the efficacy of induction of labour, e. g., the ratio of Caesarean sections was not increased. There was no impairment of foetal outcome, in contrast, the ratio of postpartal admission to NICU was decreased (42 [14.2%] vs. 31 [6.7%], p=0.0006)., Conclusion: The new recommendation of the German guideline to induce labour beyond 41 weeks leads to more cases with induction of labour without any negative impact on its efficacy or foetal outcome., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Need for cognitive closure (NFCC) has been shown to be a consistent and measurable trait. It has effects on decision making and has been associated with more rapid decision making, higher reliance on heuristics or biases for decision making, reduced tolerance for ambiguity, and reduced interest in searching for alternatives. In medical practice, these tendencies may lead to lower quality of decision making., Methods: This study measured NFCC in 312 obstetrician/gynecologists using a survey-style approach. Physicians were administered a short NFCC scale and asked questions about their clinical practice., Results: Obstetrician/gynecologists with high NFCC were found to be less likely to address a number of clinical questions during well-woman exams, and were more likely to consult a greater number of sources when prescribing new medications., Conclusions: NFCC of physicians may have an important impact on practice. It is possible that increased training during residency or medical school could counteract the detrimental effects of NFCC, and steps can be taken through increased use of electronic reminder systems could orient physicians to the appropriate questions to ask patients.

Introduction: This study explores the scope of practice of Obstetrics and Gynaecology specialists in Italy, Belgium and England, in light of the growth of professional and patient mobility within the EU which has raised concerns about a lack of standardisation of medical speciality practice and training., Methods: Semi-structured qualitative interviews were conducted with 29 obstetricians and gynaecologists from England, Belgium and Italy, exploring training and scope of practice, following a common topic guide. Interviews were recorded, transcribed and coded following a common coding framework in the language of the country concerned. Completed coding frames, written summaries and key quotes were then translated into English and were cross-analysed among the researchers to identify emerging themes and comparative findings., Results: Although medical and specialty qualifications in each country are mutually recognised, there were great differences in training regimes, with different emphases on theory versus practice and recognition of different subspecialties. However all countries shared concerns about the impact of the European Working Time Directive on trainees' skills development. Reflecting differences in models of care, the scope of practice of OBGYN varied among countries, with pronounced differences between the public and private sector within countries. Technological advances and the growth of co-morbidities resulting from ageing populations have created new opportunities and greater links with other specialties. In turn new ethical concerns around abortion and fertility have also arisen, with stark cultural differences between the countries., Conclusion: Variations exist in the training and scope of practice of OBGYN specialists among these three countries, which could have significant implications for the expectations of patients seeking care and specialists practising in other EU countries. Changes within the specialty and advances in technology are creating new opportunities and challenges, although these may widen existing differences. Harmonisation of the training and scope of practice of OBGYN within Europe remains a distant goal. Further research on the scope of practice of medical professionals would better inform future policies on professional mobility., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objective: With newer recommendations for less frequent cervical cancer screening, longer intervals between routine gynecologic examinations might also be considered., Methods: A nationally representative mailed survey of U.S. obstetrician-gynecologists (n=521, response rate 62%) was conducted in 2010-11. Clinicians were asked their views on annual gynecologic examinations and on the consequences of extending the interval from annually to every 3 years for asymptomatic patients., Results: Over two-thirds considered annual gynecologic examination very important for women in their reproductive years (69%); fewer consider it very important for women in menopause (55%). Most anticipated that shifting examinations to every 3 years would result in lower patient satisfaction (78%), contraceptive provision (74%), and patient health and well-being (74%). Decreases in clinic volume (93%) and financial reimbursement (78%) were also expected. Anticipated effects of longer intervals varied by provider characteristics, geography, and practice setting., Conclusion: Obstetrician-gynecologists in the U.S. believed that longer intervals between routine examinations would have negative repercussions for patients and medical practice, but there were differences by region, practice, and personal characteristics. Redefining annual gynecologic visits as contraceptive counseling and health maintenance visits could address financial and patient volume concerns, and perspectives from patients and other providers might reveal possible benefits of less frequent gynecologic examinations., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: In 2009, the Institute of Medicine revised gestational weight gain recommendations; revisions included body mass index (BMI) category cut-point changes and provision of range of gain for obese women. Our objective was to examine resident prenatal caregivers' knowledge of revised guidelines., Methods: Anonymous electronic survey of obstetrics/gynecology and family medicine residents across the United States from January to April 2010., Results: Overall, 660 completed the survey; 79 percent female and 69 percent aged between 21 and 30. When permitted to select ≥ 1 response, 87.0 percent reported using BMI to assess weight status at initial visits, 44.4 percent reported using "clinical impression based on patient appearance," and 1.4 percent reported not using any parameters. When asked the most important baseline parameter for providing recommendations, 35.8 percent correctly identified prepregnancy BMI, 2.1 percent reported "I don't provide guidelines," and 4.5 percent reported "I do not discuss gestational weight gain." Among respondents, 57.6 percent reported not being aware of new guidelines. Only 7.6 percent selected correct BMI ranges for each category, and only 5.8 percent selected correct gestational weight gain ranges. Only 2.3 percent correctly identified both BMI cutoffs and recommended gestational weight gain ranges per 2009 guidelines., Conclusions: Guideline knowledge is the foundation of accurate counseling, yet resident prenatal caregivers were minimally aware of the 2009 Institute of Medicine gestational weight gain guidelines almost a year after their publication., (© 2013, Copyright the Authors Journal compilation © 2013, Wiley Periodicals, Inc.)

Objective: To assess obstetrician-gynecologists' (ob-gyns') use of multiple conflicting guidelines assess after the release of the 2009 U.S. Preventive Services Task Force (USPSTF) breast cancer screening recommendations., Study Design: A nationally representative sample of American College of Obstetricians and Gynecologists (ACOG) Fellows were invited to complete a survey., Results: A total of 235 of 399 ob-gyns responded (59% response rate). Twenty percent and 89% indicated that USPSTF and ACOG guidelines influence their practice, respectively, 84% are influenced by more than one guideline. The plurality of respondents was able to correctly identify ACOG and USPSTF guidelines on 10 of 12 questions. One-third agreed with both ACOG's and USPSTF's recommendations regarding mammography screening for women 40-49 years old. A total of 42% of the sample made at least one change in their practice after the release of the 2009 USPSTF breast cancer screening guidelines., Conclusion: Some ob-gyns made changes to their practices after the release of the USPSTF guidelines. When multiple guidelines exist, as in the case with breast cancer screening, physicians utilize multiple, and at times conflicting, guidelines. More research will be needed to better understand the impact (negative or positive) of multiple guidelines on the quality of healthcare., (© 2013 National Association for Healthcare Quality.)

Objective: Less-than-annual cervical cancer screening is now recommended for most US women, raising questions about the need for routine annual bimanual pelvic examinations. Little is known about clinicians' bimanual pelvic examination practices, their beliefs about its importance, or the reasoning underlying its performance in asymptomatic women., Study Design: We conducted a nationwide survey of US obstetrician-gynecologists. Respondents (n = 521) reported their examination practices and beliefs based on vignettes for asymptomatic women across the lifespan., Results: Nearly all obstetrician-gynecologists perform bimanual pelvic examinations in asymptomatic women across the lifespan, although it is viewed as less important for a newly sexually active 18-year-old. Reasons cited as very important included adherence to standard medical practices (45%), patient reassurance (49%), detection of ovarian cancer (47%), and identification of benign uterine (59%) and ovarian (54%) conditions., Conclusion: Obstetrician-gynecologists perform bimanual pelvic examinations in the vast majority of asymptomatic women, but the importance placed on the examinations and reasons for conducting them vary., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Objective: To assess barriers to and quality of care received by diabetic pregnant women from obstetrician-gynecologists., Study Design: A questionnaire was mailed to 1,000 representative practicing Fellows of the American College of Obstetricians and Gynecologists; 74 did not treat pregnant patients and 510 (55.1%) returned completed surveys. Respondents were divided into 3 groups: maternal-fetal medicine specialists, physicians with high minority/low insurance patient populations, and physicians with low minority/ high insurance patient populations., Results: Reported preconception and prenatal care was generally consistent with guidelines. Regarding gestational diabetes mellitus patients the 3 physician groups differed in assessing postpartum glycemic status, counseling about lifestyle changes, and counseling patients to consult a doctor before their next pregnancy. Patient demographics and perceived barriers to care were similar between maternal-fetal medicine specialists and physicians with high minority/low insurance patient populations. These two physician groups were more likely to agree that lack of educational materials, arranging specialist referrals, patient compliance with recommendations, and patients' ability to afford healthful food were barriers to quality care., Conclusion: According to physician self-report, pregnant diabetic patients with access to an obstetrician receive quality care regardless of insurance status. Postpartum care is more variable. Physicians with high minority/low insurance patient populations may lack access to resources.

Background: Sample sizes for obstetrical trials are often based on the opinion of investigators about clinically important effect size. We surveyed Canadian obstetricians to investigate clinically important effect sizes required before introducing new treatments into practice to prevent preterm birth., Methods: Questionnaires were mailed to practicing obstetricians, asking the magnitude of pregnancy prolongation required to introduce treatments into practice. The three prophylactic treatments were of increasing invasiveness: vaginal progesterone, intramuscular progesterone, and cervical cerclage. We also asked about the perceived most relevant outcome measures for obstetrical trials and current obstetrical practice in preterm birth prevention., Results: 544/1293(42.1%) completed questionnaires were received. The majority of respondents required one or two weeks' increase in length of gestation before introducing vaginal (372,77.1%), and intramuscular progesterone(354,67.9%). At least three weeks increase was required before introducing prophylactic cervical cerclage(326,62.8%). Clinicians who already used a treatment required a smaller difference before introducing it into practice. Decreasing neonatal morbidity was cited as the most important outcome for obstetrical trials (349,72.2%)., Conclusion: Obstetricians would require a larger increase in treatment effect before introducing more invasive treatments into practice. Although infant morbidity was perceived as a more important outcome, clinicians appeared willing to change practice on the basis of prolongation of pregnancy, a surrogate outcome. We found that there is not a single minimum clinically important treatment effect that will influence all practising clinicians: rather the effect size that will influence physicians is affected by the nature of the treatment, the reported outcome measure and the clinician's own current clinical practice.

Aims: To determine whether healthcare providers apply the best interest principle equally to different resuscitation decisions., Methods: An anonymous questionnaire was distributed to consultants, trainees in neonatology, paediatrics, obstetrics and 4th medical students. It examined resuscitation scenarios of critically ill patients all needing immediate resuscitation. Outcomes were described including survival and potential long-term sequelae. Respondents were asked whether they would intubate, whether resuscitation was in the patients best interest, would they accept surrogate refusal to initiate resuscitation and in what order they would resuscitate., Results: The response rate was 74%. The majority would wish resuscitation for all except the 80-year-old. It was in the best interest of the 2-month-old and the 7-year-old to be resuscitated compared to the remaining scenarios (p value <0.05 for each comparison). Approximately one quarter who believed it was in a patient best interests to be resuscitated would nonetheless accept the family refusing resuscitation. Medical students were statistically more likely to advocate resuscitation in each category., Conclusion: These results suggest resuscitation is not solely related to survival or long-term outcome and the best interest principle is applied differently, more so at the beginning of life., (© 2010 The Author(s)/Acta Paediatrica © 2010 Foundation Acta Paediatrica.)

Background: Clinical guidelines have a role in medical education and in the standardization of patient care. However, it is not clear whether guidelines created by subspecialists reach relevant practicing physicians or influence patient care. In 2007 the Endocrine Society released "Guidelines on the Management of Thyroid Dysfunction During Pregnancy and Postpartum." The objective of this study was to characterize the role of these guidelines in provider education and in subsequent patient care decisions., Method: In 2009 three waves of mail surveys were distributed to 1601 Wisconsin health care providers with a history of providing obstetric care. Survey participants were members of the American College of Obstetricians and Gynecologists or the American Academy of Family Physicians. There were 881 returned surveys (55%) and 575 were eligible for the study (adjusted rate 52.5%)., Results: Although only 11.5% of providers read the Endocrine Society's guidelines, reading the guidelines was associated with increased likelihood of prepregnancy counseling on levothyroxine management (p < 0.0001), increased likelihood of screening for thyroid disease risk factors (p = 0.0007), and increased likelihood of empiric levothyroxine dose increase in pregnant patients (p = 0.0005). After controlling for provider sex, membership affiliation, practice setting, and number of years in practice, reading the guidelines was still an independent predictor of patient education prepregnancy (p < 0.01)., Conclusion: The Endocrine Society's "Guidelines on the Management of Thyroid Dysfunction During Pregnancy and Postpartum" reached a minority of providers involved in obstetrics, but exposure to the guidelines did impact patient care. A multidisciplinary approach to guideline creation would improve the dissemination and practical application of guidelines.

Objective: The purpose of this study was to determine changes in screening and performance of invasive diagnostic procedures for Down syndrome between 2001 and 2007., Study Design: The Society for Maternal-Fetal Medicine members completed a survey in 2007 regarding screening tests and diagnostic procedures for Down syndrome. With the use of descriptive statistics, the chi(2) test, and the Student t test, responses from 2007 were compared with responses from a similar 2001 survey., Results: Performance of first-trimester screening more than doubled from 2001-2007 (43.1% in 2001, 97.3% in 2007; P < .0001). Between 2001 and 2007, the use of the quad screen increased 10-fold (8.5% in 2001, 85.6% in 2007; P < .0001). There was an estimated 20% decrease in invasive diagnostic procedures that were performed in risk-positive women (53.7% in 2001, 34.2% in 2007; P < .0001). In 2007, the average fetal loss rates that were quoted by maternal-fetal medicine specialists after chorionic villous sampling was 1:160 and after an amniocentesis was 1:493., Conclusion: Down syndrome screening evolved from 2001-2007, with an increasing emphasis on first-trimester screening. With more efficacious screening, the number of invasive procedures has declined.

Objective: Determine the ability of anesthesia provider model and hospital resources to explain maternal outcome variation., Data Source/study Setting: 1,141,641 obstetrical patients from 369 hospitals that reported at least one live birth in 2002 in six representative states., Study Design: Logistic regression of death, anesthesia complication, nonanesthesia maternal complication, and obstetrical trauma for all patients and those having cesarean deliveries on anesthesia provider model, obstetrical and anesthesia, and patient variables., Data Collection/extraction Methods: Data was assembled from information given by hospitals to state agencies and from a 2004 survey of obstetrical organization resources., Principal Findings: Anesthesia complication rates in anesthesiologist-only hospitals were 0.27 percent compared with 0.23 percent in certified registered nurse anesthetist (CRNA) only hospitals. Rates among other provider models varied from 0.24 to 0.37 percent with none statistically different from the anesthesiologist-only hospitals. A similar pattern was observed for rates of other outcomes. Multivariate analysis found no systematic differences between hospitals with anesthesiologist-only models and models using CRNAs. There was no consistent pattern of association of other hospital or patient characteristics with outcomes., Conclusion: Hospitals that use only CRNAs, or a combination of CRNAs and anesthesiologists, do not have systematically poorer maternal outcomes compared with hospitals using anesthesiologist-only models.

Improved techniques and therapies have been accompanied by increased claims against obstetricians/gynecologists. Practice patterns that can decrease the risk of being sued are presented. Risks are addressed in 2 contexts: (1) medical risk, defined as the risk of an adverse outcome to a patient; (2) legal risk, defined as the risk of being sued.

Malpractice risk bedevils obstetricians. Suits can be a nuisance or emotionally and financially devastating. In this chapter, we ask simple questions and provide empiric data to demonstrate that interpersonal factors trigger suits. A supportive relationship between the obstetrician, team members, and the patient can reduce the chance of being sued after an unexpected event. Collaboration between physician colleagues and others to promote teamwork reduces error and increases patient satisfaction. Physicians who disrupt the emotional ecosystem increase liability for themselves and team members. A method of identifying physicians at increased risk and a strategy for intervening to reverse the pattern is described.

--In 2007, the Dutch Society for Obstetrics and Gynaecology issued a revised version of the 1999 guideline on recurrent miscarriage. --The new guideline was developed according to the principles of evidence-based guideline development and includes levels of evidence. --The guideline contains recommendations for effective diagnosis and treatment and explicitly mentions certain diagnostic tests and treatments that should be avoided. --After a thorough investigation of a couples'-history, the type of diagnostic tests that should be offered to the couple can be determined. Patients with a low risk of having cytogenetic abnormalities or thrombophilia may be excluded from parental karyotyping and thrombophilia screening, respectively. --Women with confirmed antiphospholipid antibody syndrome should be offered anticoagulation treatment before and during subsequent pregnancies. --Effective therapy for unexplained recurrent miscarriage is lacking. However, the probability of a successful future pregnancy is high. This probability can be estimated based on the number of previous miscarriages and maternal age.

Background: The worrying trend of an ever-increasing incidence of delivery by cesarean section has been commented on repeatedly. Studies from the United Kingdom and the United States have found that many obstetricians would choose cesarean section for themselves without strict medical indication, whereas similar studies from Denmark and Norway have indicated that almost none would choose cesarean section for themselves. The purpose of this study was to report the proportion of Norwegian obstetricians who have children born by cesarean section and to compare the rate with that among other physicians and that with the general population., Methods: Questionnaires were sent to 1,500 random members of the Norwegian general public, 1,500 randomly selected physicians, and 423 random surgeons asking whether they had children born by cesarean section. All were between the ages of 40 and 65 years., Results: The response rate was 78 percent. In the general public with children, 12 percent reported that one or more of them were born by cesarean section. The average was 8 percent among those with only basic schooling compared with 16 percent (p < 0.02) among those who had been to university for more than 4 years. This figure was 19 percent among physicians in general (p < 0.001 compared with the general population), 26 percent among surgeons, and 27 percent among the 189 specialists in obstetrics and gynecology (p < 0.02 compared with the physicians in general)., Conclusion: The rate of cesarean section in the general population is unlikely to fall as long as so many obstetricians have their own children delivered by cesarean section.

Objective: To determine whether physicians' confidence in the use of hormone replacement therapy (HRT) for climacteric symptoms has been affected by the negative media interpretation of data from landmark studies investigating HRT usage such as the Women's Health Initiative (WHI) study., Methods: A structured questionnaire was completed via the internet by European and US gynecologists, obstetrician/gynecologists and general practitioners - all experienced in treating women with climacteric symptoms., Results: Six hundred physicians completed the survey in six countries. Overall, 98% agreed that the menopause significantly affects quality of life and 97% considered that the majority/all of their patients experienced positive benefits from HRT. Most physicians (90%) believed the benefits of HRT outweigh the risks in suitable patients, and 92% would prescribe HRT for themselves/spouse/family. For treatment of atrophic vaginitis, 86% agreed that local estrogen was the most effective course of action. While 82% of participants were aware of the latest recommendations on low-dose HRT, and estrogen dose in particular, 67% cited lowering the progestogen dose as important. With regard to the recent negative media coverage on HRT, 78% of physicians felt this was unjustified., Conclusions: These results provide reassurance that health-care professionals in Europe and the US, experienced in treating women with climacteric symptoms, have not lost confidence in HRT. Despite a consensus on the importance of lowering the dose of HRT and a focus on estrogen, there remains a need to heighten prescribers' awareness on the pivotal role that a lower progestogen dose plays in optimizing the risk-benefit profile.

The purpose of this survey was to ascertain what prompts clinicians in eastern Wisconsin to change their obstetric practice. A survey was mailed to all clinicians doing obstetrics for a nonprofit organization that performs over 11,000 deliveries in 10 hospitals. Of the 185 surveys mailed, 90 (49%) practicing obstetricians returned it. To change their practice, 31% of respondents said they need the American College of Obstetricians and Gynecologists (ACOG) to recommend it; 24% required multiple randomized clinical trials (RCTs) from different centers; 11% thought one RCT was sufficient. Whereas 93% of the respondents will change their practice within 2 years of a new ACOG recommendation, only 67% will do so after an RCT (odds ratio 6.42; 95% confidence intervals 2.46, 16.75). We concluded that ACOG recommendations are more likely to change the practice of clinicians doing obstetrics in eastern Wisconsin than RCTs.

Objective: To provide recommendations for the management of genital herpes infection in women who want to get pregnant or are pregnant and for the management of genital herpes in pregnancy and strategies to prevent transmission to the infant., Outcomes: More effective management of complications of genital herpes in pregnancy and prevention of transmission of genital herpes from mother to infant., Evidence: Medline was searched for articles published in French or English related to genital herpes and pregnancy. Additional articles were identified through the references of these articles. All study types and recommendation reports were reviewed., Values: Recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care.

Objective: Evaluation of policy and treatment of deliveries at the limits of viability in the Netherlands and resulting survival figures., Design: Cohort study., Method: Within the framework of the European 'Models of organising access to intensive care for very preterm births in Europe' (MOSAIC) study, data was collected on all 512 births in 2003 (terminations excluded) following 22-31 weeks gestation in the catchment areas of the perinatal centres in Nijmegen and Utrecht, the Netherlands., Results: Gynaecologists and neonatologists practised a reserved policy for the active treatment of pregnancies under 25 weeks (5/77; 6%); all infants died. At 25 weeks, an active obstetric policy was used in one quarter of pregnancies, but none of the infants survived. Even at 26 weeks pregnancy, the obstetric policy was reserved and the mortality relatively high (9/31; 29%). From the neonatal deaths, 86 out of 92 (93%) were preceded by a decision either not to start or to discontinue treatment., Conclusion: Dutch obstetricians and neonatologists practised a reserved policy at the limits of neonatal viability. There is more need for active antenatal transfer to perinatal centres for those at the lower limit of neonatal viability to enable well-balanced decisions to take place. The parents' wishes should always be taken into account.

Asthma is a common, potentially serious medical condition that complicates approximately 4-8% of pregnancies. In general, the prevalence of and morbidity from asthma are increasing, although asthma mortality rates have decreased in recent years. The purpose of this document is to review the best available evidence about the management of asthma during pregnancy.

Objectives: This work is a study of the prophylaxis of maternal venous thromboembolism (VTE) after the publication of the French guidelines and a comparison between the practice and the guidelines., Population and Methods: Inquiry into the practice of 193 anaesthetists from maternities of the Rhône-Alps area has been made., Results: Of the 48.2% anaesthetists who answered, 92.5% of them estimate that the caesarean is a risk factor of VTE; 87% prescribe an antithrombotic treatment and 6.5% treat differently the prophylactic caesareans and the urgent ones. The classification of the risk factors is identical to the guidelines for the age, the hypertension and the prophylactic caesarean (p<0.0001). For all the other factors, the risk is overestimated, leading to an over-treatment. Eighty percent of the anaesthetists read the guidelines and 84% give them a positive value. There is a better adequacy between the guidelines and the professionals from university hospitals as compared to the non university hospitals ones (p=0.0027)., Discussion and Conclusions: Patients are managed approximately and very differently from one consultant to another. A facility of use of the guidelines will undoubtedly make it possible to obtain a more coherent attitude.

Background: We assessed current practice regarding indications and contraindications to regional analgesia and anaesthesia for labour and delivery in Germany., Methods: Questionnaires were mailed to the directors of 918 German departments of anaesthesiology., Results: A total of 397 completed replies were received representing 41.3% of all deliveries in Germany. More than half of the respondents never perform spinal or epidural anaesthesia when the platelet count falls below 65x10(9)/L. Preeclampsia, which was not graded for severity, was considered an absolute contraindication to regional block by 15% and placenta praevia by 30% of respondents. If a woman had taken aspirin three days before, the numbers of respondents considering epidural anaesthesia contraindicated (40.2%) were nearly double those considering spinal anaesthesia contraindicated (21.7%) (P<0.001). For a platelet count of 79x10(9)/L, epidural anaesthesia was thought to be contraindicated by 37% and spinal anaesthesia by 22.2% (P=0.001). In departments with <500 deliveries/year, reluctance to use regional blockade was more pronounced than in departments with >1000 deliveries/year., Conclusion: Clinical practice varies considerably in Germany. Concerns regarding the use of regional blockade were more prevalent in hospitals with small delivery units. Indications and contraindications are not consistent in Germany and some recommendations or guidelines are needed.

Objective: To examine how practicing obstetricians evaluate and manage thrombophilias in selected clinical situations., Methods: A questionnaire investigating knowledge and practice patterns pertaining to thrombophilia was mailed to 300 randomly selected American College of Obstetricians and Gynecologists Fellows and Junior Fellows in February 2005., Results: Approximately 50% (151) of questionnaires were returned. Statistical analysis focused on the 104 responding obstetricians. The majority (greater than 70%) know which thrombophilias are inherited and which are acquired. More than 50% send an inherited thrombophilia panel and antiphospholipid antibodies on patients with a history of fetal demise, intrauterine growth restriction (less than 5th percentile), abruption, and severe preeclampsia. Ninety-two percent test patients with recurrent miscarriages for antiphospholipid antibodies. Despite no clear evidence, 80% also test these patients for inherited thrombophilias. The majority intervene with either thromboprophylaxis or low-dose aspirin when managing patients at risk for thromboembolism. Seventy percent use low-molecular-weight (fractionated) heparin for patients requiring therapeutic anticoagulation, while 62% also use it for prophylactic anticoagulation. Thirty-eight percent of physicians using low-molecular-weight (fractionated) heparin monitor anti-factor Xa levels. The majority (56%) felt their residency training with regard to thrombophilia was barely adequate. Only 8% felt their training was comprehensive, while 36% felt it was adequate., Conclusion: Most responding obstetricians do not manage thrombophilia patients according to expert opinion. Despite the fact that often there is no clear evidence for treatment, many physicians are inclined to intervene in patients at risk for thromboembolism. Educational endeavors are needed to guide obstetricians caring for patients at risk for thromboembolism., Level of Evidence: III.

Objective: To investigate factors that influence the antenatal screening practice of obstetricians and identify barriers to the implementation of universal antenatal HIV screening., Design: A survey of all obstetricians registered with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists., Methods: A questionnaire was mailed to all obstetricians in Australia, followed by two reminders., Results: The overall response rate was 70% (817/1172) and of these 70% always offered an HIV test during pregnancy. Obstetricians offering the test were more likely to female or younger in age. Of respondents who always offered testing, 90% disagreed with only testing women with risk factors compared with only 34% of those who undertook a selective screening approach (adjusted odds ratio, 87.7; 95% confidence interval, 40-192; P = 0.001). Obstetricians who practiced selective screening were influenced by whether the woman had antenatal blood tests prior to her obstetric appointment or a previous negative HIV test. Obstetricians who practiced universal screening were more likely to be concerned about false-positive results. Many obstetricians, irrespective of their screening practice, agreed that many of the components of pretest counseling were inappropriate for the majority of women., Conclusions: A majority of obstetricians in Australia are offering all pregnant women an HIV test. Consideration should be given to tailoring pretest counseling requirements to the antenatal setting. Ongoing education regarding the limitations of selective screening and management of women with false-positive results is also highlighted by this study.

Background: To evaluate the impact of the 2002 Women's Health Initiative (WHI) study results on the prescription of menopausal hormone therapy (MHT) to treat menopause-related symptoms in Taiwan., Methods: This retrospective study participant data collected from women interviewed in 2001 Taiwan's National Health Interview Survey (NHIS) and the National Health Insurance (NHI) outpatient claims for women being treated for menopause-related symptoms. We compared prescriptions made for MHI to women seeking outpatient treatment for menopause-related symptoms before and after the publication of the 2002 WHI to study its effect of prescription behavior in Taiwan. There was one dichotomous outcome variable, which was whether MHT was prescribed or not in an outpatient visit to treat menopause-related symptoms., Results: Our study included 504 women 45 years old or above whose outpatient visits for menopause-related symptoms were covered by National Health Insurance in 2002. In total, these 504 women made 2549 outpatient visits to be treated for these symptoms. The proportion of outpatient visits in which MHT was prescribed dropped from 83.0% (n = 1,155) before WHI to 73.0% (n = 844) after WHI. We found a decrease in likelihood that women would be prescribed MHT for menopause-related symptoms after the release of the WHI report (OR = 0.36, 95% CI = 0.25 to 0.52, p < 0.05). Gynecologists and obstetricians are more likely to prescribe MHT than physicians with other medical specialties (5.34; 95% CI = 3.45 to 8.26, p < 0.05). Women with college level educations or higher became less likely to be prescribed MHT (Model 2; OR 0.30; 95% CI 0.11-0.83), and academic medical centers became less likely to prescribe MHT than other medical care institutions (Model 3; OR 0.15; 95% CI 0.34-0.63)., Conclusion: The WHI report caused a substantial decline in the use of MHT to treat menopause-related symptoms in Taiwan. It was found to exert most of its influence in patients with higher educations, physicians with specialties other than gynecologists and obstetricians, and academic medical centers.