Overall, the RANZCOG database identified 5409 eligible clinicians, all of whom received a standardised invitation email. This comprised of 2120 Fellows, 769 FRANZCOG trainees and 2520 Diplomates. A total of 545 valid responses were received and submitted for analysis (10.1%), less than the predicted response rate for medical personnel (32.8%) [12]. The response rate for O&G affiliates (12.9%) was consistent with gynaecologist rates from a similar risk perception study by Csajka et al (13%) [2]. The response rate for GP affiliates was 6.8%.
Demographics
Three hundred and seventy-three clinicians aligned with RANZCOG (68.4%) and 172 aligned with RACGP (31.6%). 97.8% of the clinicians saw pregnant women regularly in their clinical practice, with similar proportions of O&Gs (97.3%) and GPs (98.8%). More than half of the responders in both groups were 50 years or younger but there was a higher proportion of responders 61and above year-old amongst O&Gs (15.6%) compared to GPs (6.4%). The demographic characteristics of the respondents are shown in Table 1.
Table 1
Comparison of survey respondent demographics by clinical affiliation
Question | Overall (n (%), n = 545) | Obstetrician Gynaecologist (n (%), n = 373) | General Practitioner (n (%), n = 172) |
Age (years, n = 543) | | | |
23 to 30 | 47 (8.7%) | 34 (9.2%) | 13 (7.6%) |
31 to 40 | 182 (33.5%) | 121 (32.6%) | 61 (35.5%) |
41 to 50 | 116 (21.4%) | 81 (21.8%) | 35 (20.3%) |
51 to 60 | 129 (23.8%) | 77 (20.8%) | 52 (30.2%) |
61 or above | 69 (12.7%) | 58 (15.6%) | 11 (6.4%) |
Years in specialty (including training) (n = 542) | | | |
<10 | 212 (39.1%) | 142 (38.4%) | 70 (40.7%) |
10 or more | 330 (60.9%) | 228 (61.6%) | 102 (59.3%) |
Where was medical student training completed? (n = 541) | | | |
Australia | 391 (72.3%) | 244 (65.9%) | 147 (86.0%) |
New Zealand | 46 (8.5%) | 45 (12.2%) | 1 (0.6%) |
Other | 104 (19.2%) | 81 (21.9%) | 23 (13.5%) |
How long ago were the Fellowship training requirements completed? (n = 543) | | | |
Not yet completed | 118 (21.7%) | 97 (26.1%) | 21 (12.3%) |
< 5 | 119 (21.98%) | 79 (21.2%) | 40 (23.4%) |
5 to 10 | 72 (13.3%) | 43 (11.6%) | 29 (17.0%) |
> 10 | 234 (43.1%) | 153 (41.1%) | 81 (47.4%) |
Working capacity? (n = 543) | | | |
Full time | 407 (75.0%) | 306 (82.5%) | 101 (58.7%) |
Part time | 132 (24.3%) | 61 (16.4%) | 71 (41.3%) |
No longer clinically active | 4 (0.7%) | 4 (1.1%) | 0 (0.0%) |
You practice in a… (n = 543) | | | |
Public health facility | 198 (36.5%) | 182 (49.1%) | 16 (9.3%) |
Private health facility | 160 (29.5%) | 72 (19.4%) | 88 (51.2%) |
Both | 185 (34.1%) | 117 (31.5%) | 68 (39.5%) |
Hours working with pregnant women per week (n = 541) | | | |
Up to 10 | 222 (41.0%) | 83 (22.4%) | 139 (81.3%) |
11 or more | 319 (59.0%) | 287 (77.6%) | 32 (18.7%) |
Sixty-one percent of clinicians had over 10 years’ experience in their area of specialty. Predominantly, respondents had trained in Australian medical colleges (72.3%) with fewer trained in New Zealand (8.5%) and 19.2% trained elsewhere. Only one GP (0.6%) trained in New Zealand compared with 12.2% of O&G. 21.7% of O&Gs had not yet attained their fellowship with 43.1% of clinicians overall having been fully qualified specialist O&Gs for over 10 years. In the previous 12 months, O&Gs were more likely to have been working in a full-time capacity (82.5%) compared with GPs (58.7%). Overall O&Gs were more likely (49.1%) to have practiced in the public sector whereas GPs predominantly worked in private practice (51.2%). Unsurprisingly, 77.6% of O&Gs spent greater than 11 hours per week caring for pregnant women versus only 18.7% of GPs. The majority of the GPs (57.9%) spent less than 5 hours per week with pregnant women.
Table 1 goes here
Interest
In general, respondents had no particular interest in perinatal mental health disorders (only 36.7%), however more GPs (46.7%) were interested than O&Gs (32.1%). The vast majority of clinicians (96.9%) had not conducted any perinatal mental health research in the last five years. Also, fewer than half (46.4%) of all clinicians had attended a conference or read a journal article where AD or AX medication use in pregnancy had been reviewed. In general, only a small proportion of clinicians (15.3%) were involved in the provision of education to trainees about psychotropic prescription during pregnancy.
Perception
Figure 1 shows clinician self-reported perception of concern prescribing AD or AX medications, with O&Gs apportioning a mean score of 3.7 (SD 2.3) and GPs 3.9 (SD 2.4), indicating a relatively low level of concern. (Likert scale 0 = no concerns and 10 = extremely concerned). Likewise, there was a similar perception of the mean percentage of patient compliance between GPs and O&Gs with both groups believing that over a third of patients were not compliant with their treatment: O&Gs mean 34.8% (SD 18.7) and GPs 36.4% (SD 19.3). When asked to share their perceptions, GPs estimated their patients’ anxiety regarding AD and AX medication decision making in pregnancy as higher -mean 73.7% (SD 21.3) compared with O&Gs -mean 63.1% (SD 24.1).
Figure 1 goes here
Practice
Only 10.5% of all clinicians “very often” provided pregnant women with written information about the intended prescription AD or AX. Only 8.6% of O&G provided information “very often” compared to 14.5% of GPs.
Sources of written information were varied and the overall numbers were small. For O&Gs, most sourced UpToDate (32.2%), followed by MIMS (26.8%) and MotherRisk (13.4%). For GPs, the most commonly used resource was MIMS (27.9%) followed by “other” (19.2%) and Drug Company leaflets (15.1%). Less than 10% of all clinicians had their own practice pamphlets or relied on the pharmacists as their main source of written information. 31.9% of O&Gs provided no written information, compared with 16.4% of GPs.
If seeing a pregnant patient with mental health illness for the first time, more than half of GPs (52.6%) reported spending 15 minutes discussing potential maternal and foetal side effects of AD or AX treatment. Nearly 18% of GPs spent “most” of the consultation time discussing side effects. Comparatively, the O&Gs mostly reported spending less than five minutes on the subject (48.6%).
There was a statistically significant difference in prescription practice where AD or AX initiation was surveyed: 84.8% of GP initiated these medications, compared to 52.2% of O&G.
The GPs ranked “prior response to the medicine” as being an influential reason (60.5%) for prescribing a particular AD or AX. O&Gs on the other hand, were more influenced by a medication “a mental health practitioner has previously prescribed” (50.5%). This preponderance for O&Gs to rank a specialist mental health clinicians’ opinion highly was also demonstrated later in the questionnaire, where 55.7% of O&G would rely on the original prescriber’s management plan whereas only 11.7% GPs would.
Responses to the question relating to discontinuation of fluoxetine in a hypothetical pregnant patient signified varying practices between clinician groups. 59.1% of GPs indicated they initiate a patient consultation compared with only 18.0% O&Gs. Furthermore, response of O&Gs suggested that they would seek referral to a mental health specialist (48.8%), twelve times more often than GPs (5.3%).
Confidence
The questionnaire revealed that, overall, clinicians’ main concerns regarding AD and AX medication prescription to women of reproductive age are, in order of perceived influence medical safety profile including teratogenicity (86.9%), medical efficacy (75.2%), neonatal adaption syndrome (70.0%), and medication addiction potential (48.6%). Of note, 57.6% of GPs were concerned about maternal side effects compared to 47.3% of O&Gs.
There were differences in levels of reported confidence in medication recommendations and safety profile with 57.6% of GPs feeling confident compared to 44.2% of O&Gs. Figure 2 shows that in general, GPs consider themselves to be more confident in their knowledge and ability to manage and prescribe AD and AX medications.
Figure 2 goes here
Knowledge
Respondents were tested on their knowledge of five well-known antidepressant and anxiolytic medications and their potential teratogenicity. As demonstrated in Table 2, GPs knowledge was similar to that of O&Gs, with the majority of respondents recognising that these medications had no significant proven teratogenicity. However, up to 22.3% respondents in both clinician groups incorrectly ascribed recognised teratogenicity to a commonly used AD or AX. 12.2% of O&Gs considered “Sertraline” teratogenic, compared to 3.5% of GPs.
Table 2
Correct knowledge of teratogenicity of common AD and AX by clinical affiliation
Medication | Overall (n = 545) | Obstetrician/Gynaecologist (n = 373) | General Practitioner (n = 172) |
Sertraline | 90.6% | 87.8% | 96.5% |
Venlafaxine | 87.1% | 86.7% | 87.8% |
Amitriptyliine | 77.7% | 77.9% | 77.1% |
Mirtazapine | 82.5% | 82.8% | 81.8% |
Diazepam | 85.2% | 84.6% | 86.6% |
Table 2 goes here
Training adequacy
GP were more likely to agree that training and education had been adequate for them to feel confident in prescribing AD and AX to pregnant women (56.1%) compared to only a third of O&Gs (29.0%). When asked what would be more useful to daily practice of caring for pregnant patients, 71% of all respondents chose increased clinician education and training (equal numbers of O&Gs and GPs) over increased technological supports such as apps for smart phones. Interestingly, 67.4% of clinicians overall agreed that completion of the study questionnaire had increased their interest in pursuing more information regarding AD and AX use in pregnancy.