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APPENDIX A Summary of Methodology Used in Studies of Changes in Obstetrical Practice Appendix A summarizes the meth- odology of each study reviewed. Major differences among them and in their implications for the findings include the following. Survey Population The majority of the studies surveyed members of the society sponsor- ing the project. The proportion of all physicians who are members of a society varies both among specialties and geographically. Each of the American College of Obstetricians and Gynecologists' (ACOG) surveys used a stratified random sample of members based on the organization's nine geographical districts and the state of Florida. Residents, military personnel, and members outside the 50 states were excluded from all three ACOG surveys, and the 1987 survey also excluded Founding Life and Life Fellows (who are inactive practitioners). Ninety percent of all obstetrician-gynecologists are members of ACOG, but not all of the 90 percent are necessarily members of a state society. Conclusions drawn from these studies are based on the assumption that member physicians are representative of all practitioners. Samples Some of the studies drew samples of the membership, and others surveyed all members. For example, ACOG uses a sample of approx 187

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188 APPENDS A imately one in four, and the American Academy of Family Physicians (AAFP) surveyed its entire membership. The majority of state-specific studies surveyed the relevant society membership, but a few (for exam- ple, Texas) drew a sample. When samples were drawn, the methods used appear to have varied among the studies. Response Rates These vary widely, from 23 percent in the Texas Medical Association 1985 survey to more than 80 percent in Alabama and in the 1985 Washington State surveys of family practitioners. The median response rate for the state studies was 60.2 percent. The total response rate for the 1987 ACOG survey was 48.4 percent (N= 1,984~. Phraseology Questions were often imprecisely or suggestively worded. Almost all the studies sought to determine whether physicians were changing their practices or abandoning obstetrics altogether because of profes- sional liability concerns. Certain survey questions were worded in such a way as to make it impossible to distinguish between situations in which the physician ceased the practice of obstetrics because of age, health, or simply boredom and situations in which professional liability was the predominant factor.

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