OBJECTIVE: To compare the representation of women in obstetrics and gynecology department-based leadership to other clinical specialties while accounting for proportions of women in historical residency cohorts. METHODS: This was a cross-sectional observational study. The gender of department-based leaders (chair, vice chair, division director) and residency program directors was determined from websites of 950 academic departments of anesthesiology, diagnostic radiology, general surgery, internal medicine, neurology, obstetrics and gynecology, pathology, pediatrics, and psychiatry. Each specialty's representation ratio-proportion of leadership roles held by women in 2013 divided by proportion of residents in 1990 who were women-and 95% confidence interval (CI) were calculated. A ratio of 1 indicates proportionate representation. RESULTS: Women were significantly underrepresented among chairs for all specialties (ratios 0.60 or less, P≤.02) and division directors for all specialties except anesthesiology (ratio 1.13, 95% CI 0.87-1.46) and diagnostic radiology (ratio 0.97, 95% CI 0.81-1.16). The representation ratio for vice chair was below 1.0 for all specialties except anesthesiology; this finding reached statistical significance only for pathology, pediatrics, and psychiatry. Women were significantly overrepresented as residency program directors in general surgery, anesthesiology, obstetrics and gynecology, and pediatrics (ratios greater than 1.19, P≤.046). Obstetrics and gynecology and pediatrics had the highest proportions of residents in 1990 and department leaders in 2013 who were women. CONCLUSION: Despite having the largest proportion of leaders who were women, representation ratios demonstrate obstetrics and gynecology is behind other specialties in progression of women to departmental leadership. Women's overrepresentation as residency program directors raises concern because education-based academic tracks may not lead to major leadership roles.

OBJECTIVE: To characterize the cohort who may become senior leaders in obstetrics and gynecology by examining the gender and subspecialty of faculty in academic department administrative and educational leadership roles. METHODS: This is an observational study conducted through web sites of U.S. obstetrics and gynecology residency programs accredited in 2012-2013. RESULTS: In obstetrics and gynecology departmental administrative leadership roles, women comprised 20.4% of chairs, 36.1% of vice chairs, and 29.6% of division directors. Among educational leaders, women comprised 31.9% of fellowship directors, 47.3% of residency directors, and 66.1% of medical student clerkship directors. Chairs were most likely to be maternal-fetal medicine faculty (38.2%) followed by specialists in general obstetrics and gynecology (21.8%), reproductive endocrinologists (15.6%), and gynecologic oncologists (14.7%). Among chairs, 32.9% are male maternal-fetal medicine specialists. Family planning had the highest representation of women (80.0%) among division directors, whereas reproductive endocrinology and infertility had the lowest (15.8%). The largest proportion of women chairs, vice chairs, residency program directors, and medical student clerkship directors were specialists in general obstetrics and gynecology. CONCLUSION: Women remained underrepresented in the departmental leadership roles of chair, vice chair, division director, and fellowship director. Representation of women was closer to parity among residency program directors, in which women held just under half of positions. Nearly one in three department chairs was a male maternal-fetal medicine specialist. Compared with subspecialist leaders, specialist leaders in general obstetrics and gynecology were more likely to be women.

PROBLEM: An expanding obstetrics-gynecology department at an academic medical center was faced with too little physical space to accommodate its staff, including trainees, attending physicians, researchers, scientists, administrative leadership, nurses, physician assistants, and scheduling/phone staff. Staff also felt that the current use of space was not ideal for collaboration and innovation. APPROACH: In 2011, the department collected data on space use, using a neutral surveyor and a standardized data collection tool. Using these data, architects and facilities managers met with the department to develop a floor plan proposal for a new use of the space. Site visits, departmental meetings, literature reviews, and space mock-ups complemented the decision process. The final architectural plan was developed using an iterative process that included all disciplines within the department. OUTCOMES: The redesigned workspace accommodates more staff in a modernized, open, egalitarian setup. The authors' informal observations suggest that the physical proximity created by the new workspace has facilitated timely and civil cross-discipline communication and improvements in team-oriented behavior, both of which are important contributors to safe patient care. NEXT STEPS: This innovation is generalizable and may lead other academic departments to make similar changes. In the future, the authors plan to measure the use of the space and to relate that to outcomes, including clinical (coordination of care/patient satisfaction), administrative (absenteeism/attrition), research (grant volume), and efficiency and cost measures.

BACKGROUND: Unintended and adolescent pregnancy disproportionately affects minority populations, but the effect of age, race and ethnicity on the use of long-acting reversible contraception (LARC) has not been well studied. OBJECTIVE: The objective of this pilot study was to examine LARC use over a 5-year period among women receiving care at a Boston community health center. METHODS: Retrospective cohort study of LARC method use among black, Hispanic, and white women receiving care at the Dimock Center from 2006 to 2010. RESULTS: This study included 276 women (60.1% black, 18.5% Hispanic, and 9.1% white). LARC was not used as a first-line method in the majority (96.0%), regardless of age, race, and ethnicity; yet nearly half identified a long-acting contraceptive as their method of choice. CONCLUSIONS: The findings of this pilot study reveal opportunities to reduce unintended pregnancy through increased LARC use, which may be accomplished by provider and patient education.

BACKGROUND AND OBJECTIVES: Effective application of electrosurgical techniques requires knowledge of energy sources and electric circuits to produce desired tissue effects. A lack of electrosurgery knowledge may negatively affect patient outcomes and safety. Our objective was to survey obstetrics-gynecology trainees and faculty to assess their basic knowledge of electrosurgery concepts as a needs assessment for formal electrosurgery training. METHODS: We performed an observational study with a sample of convenience at 2 academic hospitals (Beth Israel Deaconess Medical Center and Mount Auburn Hospital). Grand rounds dedicated to electrosurgery teaching were conducted at each department of obstetrics and gynecology, where a short electrosurgery multiple-choice examination was administered to attendees. RESULTS: The face validity of the test content was obtained from a gynecologic electrosurgery specialist. Forty-four individuals completed the examination. Test scores were analyzed by level of training to investigate whether scores positively correlated with more advanced career stages. The median test score was 45.5% among all participants (interquartile range, 36.4%-54.5%). Senior residents scored the highest (median score, 54.5%), followed by attendings (median score, 45.5%), junior residents and fellows (median score in both groups, 36.4%), and medical students (median score, 27.3%). CONCLUSION: Although surgeons have used electrosurgery for nearly a century, it remains poorly understood by most obstetrician-gynecologists. Senior residents, attendings, junior residents, and medical students all show a general deficiency in electrosurgery comprehension. This study suggests that there is a need for formal electrosurgery training. A standardized electrosurgery curriculum with a workshop component demonstrating clinically useful concepts essential for safe surgical practice is advised.

OBJECTIVE: To determine the prepartum prevalence of cervical Mycoplasma genitalium colonization and evaluate prospectively whether colonization is associated with preterm delivery among women from a racial/ethnic minority background with a high risk of delivering a low birth weight newborn and a high prevalence of sexually transmitted infections. METHODS: In a prospective cohort study at an urban community health center in Roxbury, MA, USA, 100 women receiving routine prenatal care for singleton pregnancies were enrolled between August 2010 and December 2011. Endocervical samples were tested for M. genitalium, and delivery data were collected. RESULTS: The prevalence of M. genitalium colonization at the first prenatal visit was 8.4%. The incidence of low birth weight was 16.7%. The incidence of preterm delivery among women who were known to have a live birth was 16.7%. The incidence of preterm delivery did not differ with respect to M. genitalium colonization. The crude odds ratio for preterm delivery among women with M. genitalium colonization versus those without was 1.27 (95% confidence interval, 0.02-14.78). CONCLUSION: M. genitalium colonization was not associated with preterm delivery among women with a high incidence of low birth weight newborns and preterm delivery, and a high prevalence of sexually transmitted infections.

Nutrition is a known, powerful determinant of perinatal health and one that is increasingly recognized to have further reaching effects than previously understood. It is well known that healthy nutrition during the peripartum period can prevent birth defects in the neonate. New research suggests that peripartum nutrition may also modulate the risk of chronic disease in later life. Proper nutrition and weight gain during pregnancy also have maternal benefits including lowered risks of pregnancy related disorders. Good peripartum nutrition is a potential tool to impact the rising prevalence of obesity and related health disorders. This article will review nutrition guidance in pregnancy including macro and micronutrient recommendations, newer recommendations for appropriate weight gain based upon body mass index categories, and avoidance of potentially harmful substances. Current topics will also be discussed including fetal origins of adult disease, pregnancy after weight loss surgery, environmental bisphosphonates, and glycemic index diets.

OBJECTIVE: The objectives were to determine (i) whether simulation training results in short-term and long-term improvement in the management of uncommon but critical obstetrical events and (ii) to determine whether there was additional benefit from annual exposure to the workshop. METHODS: Physicians completed a pretest to measure knowledge and confidence in the management of eclampsia, shoulder dystocia, postpartum hemorrhage and vacuum-assisted vaginal delivery. They then attended a simulation workshop and immediately completed a posttest. Residents completed the same posttests 4 and 12 months later, and attending physicians completed the posttest at 12 months. Physicians participated in the same simulation workshop 1 year later and then completed a final posttest. Scores were compared using paired t-tests. RESULTS: Physicians demonstrated improved knowledge and comfort immediately after simulation. Residents maintained this improvement at 1 year. Attending physicians remained more comfortable managing these scenarios up to 1 year later; however, knowledge retention diminished with time. Repeating the simulation after 1 year brought additional improvement to physicians. CONCLUSION: Simulation training can result in short-term and contribute to long-term improvement in objective measures of knowledge and comfort level in managing uncommon but critical obstetrical events. Repeat exposure to simulation training after 1 year can yield additional benefits.

OBJECTIVE: To estimate the extent to which intimate partner violence (IPV), at the levels of the individual and the community, is associated with shortened interbirth intervals among women in sub-Saharan Africa. METHODS: We analyzed demographic and health survey data from 11 countries in sub-Saharan Africa. Only multiparous women were included in the analysis. Interbirth interval was the primary outcome. Personal history of IPV was measured using a modified Conflict Tactics Scale. Community prevalence of IPV was measured as the proportion of women in each village reporting a personal history of IPV. We used multilevel modeling to account for the hierarchical structure of the data, allowing us to partition the variation in birth intervals to the four different levels (births, individuals, villages, and countries). RESULTS: Among the 46,697 women in the sample, 11,730 (25.1%) reported a personal history of physical violence and 4,935 (10.6%) reported a personal history of sexual violence. In the multivariable regression model, interbirth intervals were inversely associated with personal history of physical violence (regression coefficient b=-0.60, 95% confidence interval -0.91 to -0.28) and the community prevalence of physical violence (b=-1.41, 95% confidence interval -2.41 to -0.40). Estimated associations with sexual violence were of similar statistical significance and magnitude. CONCLUSION: Both personal history of IPV and the community prevalence of IPV have independent and statistically significant associations with shorter interbirth intervals. LEVEL OF EVIDENCE: II.

OBJECTIVE: The American Congress of Obstetricians and Gynecologists (ACOG) recently recommended that cervical cancer screening begin at 21 years of age and occur biennially for low-risk women younger than 30 years. Earlier studies suggested that women may have limited understanding of the differences between cervical cancer screening and chlamydia screening. This study assessed the knowledge of chlamydia and cervical cancer screening tests and schedules in younger women. METHODS: A survey regarding knowledge of chlamydia and cervical cancer screening was administered to 60 younger women aged 18-25 years in an obstetrics and gynaecology clinic at an urban community health centre. RESULTS: The majority of respondents recalled having had a Pap smear (93.3%) or chlamydia test (75.0%). Although many respondents understood that a Pap smear checks for cervical cancer (88.3%) and human papillomavirus (68.3%), 71.7% mistakenly believed that a Pap smear screens for chlamydia. No respondent correctly identified the revised cervical cancer screening schedule, and 83.3% selected annual screening. Few respondents (23.3%) identified the annual chlamydia screening schedule and 26.7% were unsure. CONCLUSION: Many younger women in an urban community health centre believed that cervical cancer screening also screens for chlamydia and were confused about chlamydia screening schedules. As there is limited knowledge of the revised ACOG cervical cancer screening guidelines, there is a risk that currently low chlamydia screening rates may decrease further after these new guidelines are better known. Obstetrician gynaecologists and primary care providers should educate younger women about the differences between chlamydia and cervical cancer screening and encourage sexually active younger women to have annual chlamydia screening.

BACKGROUND: Residents play a significant role in teaching, but formal training, feedback, and evaluation are needed. AIMS: Our aims were to assess resident teaching skills in the resident-as-teacher program, quantify correlations of faculty evaluations with resident self-evaluations, compare resident-as-teacher evaluations with clinical evaluations, and evaluate the resident-as-teacher program. METHOD: The resident-as-teacher training program is a simulated, videotaped teaching encounter with a trained medical student and standardized teaching evaluation tool. Evaluations from the resident-as-teacher training program were compared to evaluations of resident teaching done by faculty, residents, and medical students from the clinical setting. RESULTS: Faculty evaluation of resident teaching skills in the resident-as-teacher program showed a mean total score of 4.5 ± 0.5 with statistically significant correlations between faculty assessment and resident self-evaluations (r = 0.47; p < 0.001). However, resident self-evaluation of teaching skill was lower than faculty evaluation (mean difference: 0.4; 95% CI 0.3-0.6). When compared to the clinical setting, resident-as-teacher evaluations were significantly correlated with faculty and resident evaluations, but not medical student evaluations. Evaluations from both the resident-as-teacher program and the clinical setting improved with duration of residency. CONCLUSIONS: The resident-as-teacher program provides a method to train, give feedback, and evaluate resident teaching.

OBJECTIVE: To describe our experience with the Fundamentals of Laparoscopic Surgery (FLS) program as a teaching and assessment tool for basic laparoscopic competency among gynecology residents. METHODS: A prospective observational study was conducted at a single academic institution. Before the FLS program was introduced, baseline FLS testing was offered to residents and gynecology division directors. Test scores were analyzed by training level and self-reported surgical experience. After implementing a minimally invasive gynecologic surgical curriculum, third-year residents were retested. RESULTS: The pass rates for baseline FLS skills testing were 0% for first-year residents, 50% for second-year residents, and 75% for third- and fourth-year residents. The pass rates for baseline cognitive testing were 60% for first- and second-year residents, 67% for third-year residents, and 40% for fourth-year residents. When comparing junior and senior residents, there was a significant difference in pass rates for the skills test (P=.007) but not the cognitive test (P=.068). Self-reported surgical experience strongly correlated with skills scores (r-value=0.97, P=.0048), but not cognitive scores (r-value=0.20, P=.6265). After implementing a curriculum, 100% of the third-year residents passed the skills test, and 92% passed the cognitive examination. CONCLUSIONS: The FLS skills test may be a valuable assessment tool for gynecology residents. The cognitive test may need further adaptation for applicability to gynecologists.

This quality improvement study aims to examine knowledge and attitudes about human papillomavirus (HPV) vaccination among women ages 18 through 26 in a Boston community health center to increase uptake of the HPV vaccine in the local community. This cross-sectional study was conducted from August 2007 to July 2008 at an urban community health center in Roxbury, Massachusetts. Women offered HPV vaccines were asked to complete a questionnaire. Eighty-four percent of participants had heard of the HPV vaccine. A higher percentage (69%) of minority women in this study as compared with those in other studies knew the vaccine protects against cervical cancer. Forty-two percent of women came to their appointment for the purpose of being vaccinated. The remaining 58% came for another reason and received vaccination upon health care provider recommendation. Only 38% of participants reported perceived risk for HPV infection as a motivation for vaccination. These findings suggest that generalizations of attitudes and knowledge about the HPV vaccine should not be made with regard to race and ethnicity alone, but rather need to be based on surveys of the specific local population served. In addition, education about HPV risk should be continued, especially about risk factors for HPV infection.