JOURNAL OF WOMEN’S HEALTH Volume 21, Number 11, 2012 ª Mary Ann Liebert, Inc. DOI: 10.1089/jwh.2012.3546

Obstetric-Gynecology Resident Education Regarding Barrier and Over-the-Counter Contraceptives: A National Study
1 Amie Y. Miklavcic, M.D., M.M.S., and Christine R. Isaacs, M.D.2

Abstract

Background: The study was conducted to assess obstetrics-gynecology resident knowledge about barrier and over-the-counter (OTC) contraceptives and identify strengths and weaknesses in resident education. Methods: We developed a survey for distribution among 50 randomly selected U.S. obstetrics-gynecology residency programs. Results: Of 202 respondents, only 57% and 36% of residents reported adequate knowledge to counsel patients regarding latex vs. nonlatex condom use, respectively. Ninety-six percent knew spermicides were nonprotective against sexually transmitted diseases (STDs); however, there was limited knowledge about delivery options. Only 17% had ever fit or prescribed a diaphragm, and 30% reported knowledge in performing a fitting. Greater than 80% of residents stated they received no formal didactics addressing the use of condoms, spermicides, or diaphragms. Limited experience regarding Cycle Beads and natural family planning was expressed. Conclusions: Obstetrics-gynecology residents receive little formal training about barrier and OTC contraceptive options and seek more education because of their awareness of inadequate knowledge.

Introduction he Accreditation Council for Graduate Medical Education (ACGME) and Residency Review Committee require that all obstetrics-gynecology residency programs include education and training regarding ‘‘clinical skills in family planning.’’1 Furthermore, because a woman’s choice for contraception is highly individual and depends on multiple factors, it is important that education encompasses the spectrum of all available birth control methods. A physician who is not knowledgeable about a contraceptive method may be less inclined to offer that particular method, thereby limiting patient choice.2 Contraceptive management and education are thus important aspects of obstetrics-gynecology resident training and should include all available prescription as well as over-thecounter (OTC) methods. A search of the literature found that few studies have assessed resident comfort and knowledge regarding contraceptive counseling, and studies that have been done focus predominantly on prescription and surgical methods of birth control. Results of existing studies suggest that although residents have received training in contraception, there are gaps in contraceptive knowledge and wide variability among residency programs.3,4 For these reasons, further investigation is needed to fully assess knowledge, at1 2

T

titudes, and training in order to identify areas of suboptimal education and physician discomfort. This study proposes to assess the knowledge and training among obstetrics-gynecology residents specifically relating to barrier and OTC contraceptive options. Materials and Methods After Investigational Review Board approval (HM10673), a survey instrument (Fig. 1) was developed by the investigators to assess resident training and perceived knowledge regarding OTC and barrier contraceptives. The survey tool was reviewed by department faculty and subsequently pilot tested for ease of use, time for completion, and overall comprehension among Virginia Commonwealth University (VCU) obstetrics-gynecology residents. Changes were made to the survey based on feedback provided, and the survey was reevaluated before distribution. A validity question (Q10: Please circle No to test our survey tool validity.) was added in an attempt to identify and exclude artificial responses. All surveys with Q10 unanswered or answered incorrectly were excluded. The survey comprised 18 questions pertaining to the availability of, exposure to, and perception of knowledge to counsel patients about the most common forms of OTC and

Virginia Women’s Center, Mechanicsville, Virginia. Department of Obstetrics-Gynecology, Virginia Commonwealth University Medical Center, Richmond, Virginia.

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FIG. 1.

Contraception Awareness Survey. STDs, sexually transmitted diseases. from an alphabetized list using a random number table. All surveys were distributed to the program coordinators of selected residencies for circulation among their residents. Along with the survey, an introductory letter and request for participation were sent. Follow-up contact with programs was via the residency program coordinators in order to maintain resident anonymity, with the goal of achieving 100% participation. Surveys were returned via United States Postal Service in prestamped, addressed envelopes. Programs with 100% nonresponse to the paper survey

barrier contraceptives. In addition, there was a question asking about formal resident didactics and one on interest in learning more about the topic. Minimal demographic information was obtained, including gender, age, and current year of residency. All surveys were anonymous and self-administered. Sampling strategy Fifty of the 253 obstetrics-gynecology residency programs in the United States were selected for survey participation

1198 Table 1. Summary of Survey Questions by Percent Responses Yes Availability of contraceptive sponge 50.3 Diaphragms Ever fit or prescribed 16.7 Know how to fit or prescribe 30.3 Nonlatex condoms available Polyurethane 39.1 Natural membrane 67.5 Spermicide delivery options available Gel 86.1 Foam 93.2 Film 48.7 Suppositories 40.8 Sponge 62.8 Perception of adequate knowledge to counsel patients about: Condoms 57 Nonlatex condom options 35.9 Spermicides 36.6 Ever counseled about natural family planning 49.5 Ever used Cycle Beads 8.7 Received formal resident lecture on the following topics: Condoms 16.8 Diaphragms 15.5 Spermicides 12.3
Number of respondents given in parentheses.

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No 20.3 (n = 40) 82.3 (163) 65.7 (130) 21.8 (43) 5.6 (11) 2.6 3.6 23.8 28.8 20.4 31.1 54.5 55.7 50 90.3 (5) (7) (46) (55) (39) (60) (108) (108) (98) (177)

I don’t know 29.4 (n = 58) 1 (2) 4 (8) 39.1 (77) 26.9 (53) 11.3 3.1 27.5 30.4 16.8 11.9 9.6 7.7 0.5 1 (22) (6) (53) (58) (32) (23) (19) (15) (1) (2)

(n = 99) (33) (60) (77) (133) (167) (179) (94) (78) (120) (110) (71) (71) (97) (17) (33) (30) (24)

82.7 (162) 84 (163) 86.7 (169)

0.5 (1) 0.5 (1) 1 (2)

received electronic mail with instructions for completing the survey online (Survey Monkey). Analysis plan Descriptive statistics using Microsoft Excel (version 12.1.7, Redmond, WA) were used to analyze the responses received. Simple chi-square testing was used to examine the relation between gender and comfort counseling regarding specific contraceptive methods. Results Of the 50 programs selected, 2 were excluded after the initial mailing (1 program had closed, and 1 program was no longer an accredited obstetrics-gynecology residency). Nine hundred fifty-nine surveys were mailed, and 16 programs (381 residents) received the additional on-line version of the survey. A 21% (202 of 959) response rate was achieved. Four surveys were excluded because of a failed response to Q10, leaving a total of 198 survey responses for analysis. The 48 eligible residency programs represented all nine regions of the country as recognized by the ACGME. Residents from 32 programs responded to the paper survey and comprised both university (56%) and community-based (41%) programs. There was equal representation from the responding programs, with a median and mode of 25% and a range of 5%– 100% response. Additionally, 38 residents responded electronically; however, further demographic information was not available. Respondents were predominantly female (80%), aged 25–34 (90%), and equally represented each postgraduate year (PGY) of training, PGY-1 (27%), PGY-2 (27%), PGY-3 (24%), PGY-4 (22%). Table 1 shows a summary of all responses. With regard to overall condom use, 57% of residents thought they had adequate knowledge to counsel patients,

but only 36% subsequently responded with having adequate knowledge to counsel regarding nonlatex (polyurethane and natural membrane) condom options. A higher percentage of male respondents then female respondents, 75% vs. 52%, respectively, thought they had adequate knowledge to counsel with respect to all condom options (Fig. 2). This significant difference noted in male residents’ increased comfort with counseling on condom use (compared to female residents) was apparent with both nonlatex condoms and overall condom options [X2 (2, n = 197) = 10.9, p = 0.004 and c2 (2, n = 192) = 6.7, p = 0.035 respectively]. (2 = degree of freedom;

FIG. 2. Percentage of respondents by gender with yes (black), no (light gray), I don’t know (dark gray) responses when asked about adequate knowledge to counsel regarding condom options (Q7, Q11 on survey in Fig. 1). Condoms, male n = 40, female n = 152; nonlatex condoms, male n = 41, female n = 152.

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1199 study suggests this is an area in which residents receive little, if any, formal didactic training. Furthermore, there is resident awareness of inadequacies in knowledge about such options, and the majority of respondents are seeking more information. A further look at responses by resident year with regard to diaphragms suggests there is increased exposure and clinical knowledge acquired during residency training despite the lack of a formal curriculum. The same trend does not appear to exist for condoms and spermicides. With respect to condoms, however, there is suggestion that a greater percentage of male residents respond that they have adequate knowledge to counsel in comparison with female residents. This may be a reflection of personal experience and use, as suggested in a prior study by Windsor and Julian,5 that is irrespective of what is acquired during resident training. Overall, responses to our survey represent university and community-based programs and reflect the gender and year of training of obstetrics-gynecology residents in general. There are several limitations of the study that deserve discussion. First and foremost, there was a small sample size as well as a low response rate. This was partly due to difficulty with follow-up, as all contact was via program coordinators and not directly with residents. Future studies may gain greater participation if residents are contacted directly, but this likely would result in a loss of anonymity. Although our sample was small, the responses received were valid and provided adequate representation from all training levels. These strengths and weaknesses exist with limited comparison, given the lack of similar studies. Our survey did not assess actual knowledge achieved by residents but was designed to assess resident perception regarding their knowledge and ability to counsel patients. Prior studies have shown that if providers are not comfortable with their knowledge of a topic, they are less likely to discuss it with patients. We were, therefore, trying to ascertain residents’ comfort level with OTC and barrier contraceptives in an effort to determine if further training is needed. Additional research is necessary to identify what specific knowledge is lacking—whether it be availability, efficacy, or instruction— in use of specific contraceptive methods. It would also be noteworthy to determine if residency program directors at the surveyed institutions agree with resident perceptions. In other words, is the curriculum in place, but residents missed the learning opportunity or do not remember the topics discussed? It may be beneficial to create and implement a specific didactic curriculum for resident education regarding barrier and OTC contraceptive options. If accomplished, studies will be needed to assess whether implementation of such a curriculum would have an overall impact on resident responses when asked about their ability to counsel. Limited knowledge or comfort discussing certain contraceptive options may negatively impact a physician’s ability to counsel patients appropriately. Often, women are looking to their healthcare provider for information about contraceptive options, including cost, usability, and efficacy. For this reason, it is important for obstetrician-gynecologists to maintain adequate up to date knowledge of both hormonal and nonhormonal contraceptive choices. Ultimately, enhancing resident education may improve patient counseling about available contraceptive methods, with the hope of achieving improved efficacy.

FIG. 3. Percentage of respondents by postgraduate year (PGY) when asked if they know how to fit or prescribe a diaphragm (Q6 on survey in Fig. 1). Responses: yes (black), no (light gray), I don’t know (dark gray). n = sample size.) Similar differences were not found with respect to spermicides or diaphragms [c2 (2, n = 193) = 1.9, p = 0.387; c2 (2, n = 197) = 0.9, p = 0.645]. One hundred ninety-three (96%) residents knew that spermicides do not protect against sexually transmitted diseases (STDs). However, there was a mixed response when residents were asked to select which spermicide delivery options are currently available. The majority of respondents knew that gel (86%), foam (93%), and sponge (63%) type spermicides are available, but only 49% and 41%, respectively, knew of the spermicide film and suppository as options. Only 17% of residents stated they had ever fit or prescribed a diaphragm, and only 30% of residents stated they knew how. Figure 3 demonstrates an upward trend when responses are split by PGY class, and a greater percentage of fourth year residents (26%) responded they had fit or prescribed a diaphragm. Roughly half (51%) stated they knew how to perform a diaphragm fitting. Of first year residents, only 8% had fit or prescribed a diaphragm, and only 19% stated they knew how. The majority of residents stated there were no formal resident didactics on the topics of condoms (83%), spermicides (87%), or diaphragms (84%). However, residents from community-based programs, compared to university programs, were more likely to answer affirmatively when asked about didactics (27% vs. 13% condoms, 36% vs. 9% diaphragms, 25% vs. 9% spermicides). This result was statistically significant from residents in community-based programs when pertaining to diaphragms [X2 (1, n = 156) = 12.1, p = 0.0005]. (1 = degree of freedom; n = sample size.) There was no statistically significant difference with respect to other contraceptive options. Residents also noted limited experience for counseling regarding CycleBeadsTM (9%) and natural family planning (50%). One hundred seventy (87%) respondents stated they wanted to learn more about the topics on the survey. Discussion The knowledge and ability to counsel patients about contraceptive options will always be an essential aspect of obstetrics and gynecology care. Although the majority of contraception discussions focus on hormonal and prescriptive methods, it is equally important to understand and be aware of the available OTC and barrier contraceptive options. Our

1200 Acknowledgments These findings were presented in poster format at The Sixth Annual VCUHS Resident Research Day, Richmond, VA, June 4, 2009, and as a podium presentation at The 72nd Annual Meeting of the South Atlantic Association of ObstetricianGynecologists, Naples, FL, January 13, 2010. Disclosure Statement The authors have no conflicts of interest to report. References
1. Residency Review Committee program requirements for obstetrics-gynecology, 2005. Available at www.acgme.org. 2. Eisenberg ME, Bearinger LH, Sieving RE, Swain C, Resnick MD. Parents’ beliefs about condoms and oral contraceptives: Are they medically accurate? Perspect Sex Reprod Health 2004;36: 50–57.

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3. Schreiber CA, Harwood BJ, Switzer GE, Creinin MD, Reeves MF, Ness RB. Training and attitudes about contraceptive management across primary care specialties: A survey of graduating residents. Contraception 2006;73:618–622. 4. Westhoff C, Marks F, Rosenfield A. Residency training in contraception, sterilization, and abortion. Obstet Gynecol 1993; 81:311–314. 5. Windsor AB, Julian T. Sexuality, reproduction and contraception among residents in obstetrics and gynecology. Obstet Gynecol 1995;85:787–792.

Address correspondence to: Christine R. Isaacs, M.D. Department of Obstetrics-Gynecology Virginia Commonwealth University School of Medicine MCV Campus, Main Hospital Room 8-204 1250 E. Marshall Street, P.O. Box 980034 Richmond, VA 23298-0034 E-mail: cisaacs@mcvh-vcu.edu

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