Introduction 1 1 2 3 4 5 6 7 8 Materials and methods 9 The survey recorded demographic details of physicians and their patient population, and assessed practices and opinions regarding PCC. A questionnaire concerning screening for aneuploidy was included in the same mailing; both questionnaires shared a demographics section containing 9 questions on one page. The PCC questionnaire contained 11 questions, some multi-part, on two pages. Both questionnaires were brief and resulted in a final document of 3 double-sided pages, a standard length for our full-length questionnaires. Seven of the 11 questions on PCC involved rating the frequency of an activity (e.g., always, usually, occasionally, never) or degree of agreement with a statement, and three questions were of a multiple-choice format. The questionnaires were developed in consultation with medical specialists and were pilot tested on a sample of practicing obstetrician-gynecologists prior to final distribution. ® t 2 2 Results Demographics A total of 670 questionnaires were returned. Data from 18 respondents were judged invalid (physician retired, returned to sender), resulting in a valid response rate of 60% (652/1087), 432 from CARN members (72.1% response rate) and 220 from Non-CARN (45.1% response rate). Physicians responded from every state of the United States except Maine, as well as the District of Columbia, Puerto Rico, Canada, and overseas military installations. The respondents’ mean age (47.32±0.39) and the proportion of males to females (males = 55%) closely matched those of the larger population to whom the survey was sent (46.99±0.32, males = 55%) and of ACOG Fellows and Junior Fellows in Practice as a whole (47.64, males = 58%). 1 Table 1 Physician demographics  n Gender (%)   Males 53.9  Females 46.1 CARN 67.5 Non-CARN 32.5 * 47.12 (0.42)  Males 50.88 (0.54)  Females 42.76 (0.54) Years in practice, mean (SEM) 15.22 (0.41) Deliveries in 2003, mean (SEM) 129.65 (3.13) Practice location (%)   Urban, inner city 10.7  Urban, non-inner city 29.3  Suburban 32.1  Mid-sized town 19.4  Rural 6.9  Other 1.6 Practice type (%)   Ob/Gyn partnership/gp 51.4  Solo practice 22.5  Multi-specialty 10.4  University full-time faculty and practice 8.5  Other 7.2 Patient ethnicity—mean (SEM) % of patients   Non-Hispanic white 62.29 (1.10)  African-American 16.78 (0.79)  Hispanic 13.35 (0.78)  Asian/Pacific Islander 3.83 (0.29)  Native American 1.29 (0.23) * P Defining preconception care specialized routine t P Recommending PCC 2 U P P Table 2 Percent of physicians indicating how frequently they recommend PCC to different groups of women How frequently do you recommend preconception     care to the following women of childbearing age? Always Usually Occasionally Never Diabetic women planning a pregnancy 89.9 7.9 1.7 0.5 Women who are planning a pregnancy 75.0 19.2 5.0 0.8 Obese women planning a pregnancy 61.5 27.0 9.5 2.0 Women indicating they want children in the future 38.5 43.5 16.0 2.0 Women who are sexually active 19.1 34.9 38.6 7.4 Women who are using birth control 11.5 24.1 45.9 18.5 Opinions about PCC 3 P P Table 3 Percent of physicians indicating how strongly they agree with several statement regarding PCC  Strongly    Strongly   agree    disagree Mean on 5 pt  Six statements regarding opinions about PCC 5 4 3 2 1 scale (SEM) Factor I: positive aspects        Preconception care is an important issue 47.4 39.9 10.5 1.3 0.9 4.32 (0.034)  Preconception care has a positive effect on pregnancy outcomes 44.7 38.8 14.3 1.1 1.1 4.25 (0.035)  Preconception care is a high priority in my workload 6.8 13.9 42.3 27.9 9.1 2.82 (0.043) Factor II: negative aspects        Time devoted to preconception care is not reimbursed 24.7 25.1 30.8 14.0 5.5 3.50 (0.051)  There is not enough time to provide preconception care visits to all women of childbearing age 22.6 28.8 19.7 18.9 10.0 3.35 (0.056)  I do not have appropriate training to provide preconception care 3.0 5.2 14.7 35.7 41.4 1.92 (0.044) Counseling in PCC Almost a third (31.9%) of physicians said they discuss screening for aneuploidy with All patients who present for preconception counseling. Of those not selecting All, 80.7% said they did so with patients at risk for aneuploidy. Almost one-in-ten (9.8%) said they did not discuss aneuploidy. The majority (54.4%) of physicians said they discuss carrier screening for heritable genetic disorders (e.g., CF, sickle cell anemia) with All patients who present for preconception counseling, and, of those not selecting All, 84.8% said they did so with patients who have a family history of heritable genetic disorders or other risk factors. Only 4.3% said they did not discuss carrier screening. 4 P P Table 4 Percent of physicians indicating how important they think counseling is on several issues for patients who (a) come in for a routine office exam, and (b) those who are planning a pregnancy  (Rank of mean      Importance Very important  Not important Mean (SEM)   within a or b)  Neutral [3–5]  on 7 pt scale Factor I       Folic acid supplements:        (a) routine exam (10) 36.8 52.5 10.7 4.88 (0.07)   (b) preconception care (2) 96.4 3.4 .2 6.83 (0.03) Factor II       Cigarette smoking:        (a) routine exam (1) 89.2 10.6 0.2 6.57 (0.03)   (b) preconception care (1) 98.4 1.6 0.0 6.86 (0.02)  Illegal drug use:        (a) routine exam (2) 83.2 15.2 1.6 6.40 (0.05)   (b) preconception care (3) 94.5 5.1 0.4 6.74 (0.03)  Alcohol consumption:        (a) routine exam (7) 49.1 46.5 4.4 5.40 (0.06)   (b) preconception care (4) 88.5 11.5 0.0 6.57 (0.03) Factor III       Obesity:        (a) routine exam (3) 76.1 23.7 0.2 6.11 (0.04)   (b) preconception care (7) 82.7 17.3 0.0 6.30 (0.04)  Exercise:        (a) routine exam (4) 67.0 31.4 1.6 5.87 (0.05)   (b) preconception care (10) 68.3 31.0 0.7 5.94 (0.05)  General Nutrition:        (a) routine exam (6) 51.2 46.7 2.1 5.51 (0.06)   (b) preconception care (8) 82.2 17.5 0.4 6.28 (0.04) Factor IV       Chronic diseases:        (a) routine exam (5) 63.8 34.9 1.2 5.79 (0.05)   (b) preconception care (6) 88.3 10.8 0.9 6.45 (0.04)  Family health history (inherited disorders):        (a) routine exam (8) 51.5 43.9 4.6 5.38 (0.06)   (b) preconception care (5) 90.6 9.2 0.2 6.55 (0.04)  Over the counter and prescription drug use:        (a) routine exam (9) 42.0 51.4 6.5 5.08 (0.06)   (b) preconception care (9) 81.6 17.7 0.7 6.27 (0.04)  Environmental concerns:        (a) routine exam (11) 19.9 66.3 13.9 4.25 (0.06)   (b) preconception care (11) 56.1 39.1 4.8 5.47 (0.06) 4 F P t P F P Patient use of PCC 5 P 2 P P Table 5 Patient use of pre-pregnancy planning Percent of physicians selecting a particular response to questionnaire items: How frequently do you have patients present for PCC? Never or rarely Sometimes Frequently  32.3 48.5 17.3 Women that I see usually do not plan their pregnancies  Agree (1–2) Neutral (3) Disagree (4–5)  (on a 5 point scale) 34.7 33.8 31.6 How many of your pregnant patients came in for  None Few Some Half or More  preconception care before they became pregnant? (OB) 3.3 45.8 38.3 12.6 How many of your pregnant patients initially made  All Most Many Half or Fewer  contact with you once they were already pregnant? (OB) 9.4 53.7 18.0 18.9 Physicians were asked to indicate how many of the patients who presented for PCC did so for each of three reasons (7 point scale: None Few Some Half Many Most All). Over four-fifths (82.7%) of physicians indicated that more than half of the patients do so to ensure a healthy pregnancy (mean 5.63±0.062 on 7 pt scale). In contrast, 41.9% said more than half do so because of difficulties conceiving (mean 4.05±.058), and 20.0% said more than half do so because of an elevated risk of a birth defect or developmental disorder (mean 3.13±0.064). Discussion 3 7 10 11 2 4 Our study has limitations that should be acknowledged. The response rate was 60%, and our findings are based on the responses of 579 non-subspecialist obstetricians and gynecologists. While our study may be subject to non-response bias, we believe that our findings are reliable. The typical response rate in these survey studies is approximately 35–60%, and our response rate was at the high end of expected participation. In addition, the responses were derived from geographically diverse locations and from physicians from different practice types reflecting the influence of physician location and practice type. Whereas physicians who were more interested in the topic of the survey may have been more likely to respond, a subset of our subject pool was comprised of CARN members who respond to several questionnaires a year covering a wide variety of topics; it is unlikely that Preconception Care is a topic of greater interest to this group than to the group of randomly selected ACOG members. CARN members differed significantly from non-CARN subjects on only one non-demographic response, and the mean age and male to female ratio of respondents closely matched those of the larger group to whom the survey was sent and of ACOG Fellows and Junior Fellows as a whole, all of which suggests that response bias was minimized. 10 12 13 Obstetrician-gynecologists recognize the importance of preconception care and provide this care for their patients. However, lack of third party reimbursement, lack of time during office visits due to competing demands, and lack of consumer awareness pose barriers to effective implementation of PCC. The fact that almost half of all pregnancies in the U.S. are unplanned poses an even greater challenge. Continued efforts are needed to raise awareness of the importance of PCC by consumers, health care providers, third party carriers, and policy makers.