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Aim: To provide information including the trend of gynecological malignancies in Japan, we hereby present the Annual Patient Report for 2017 and the Annual Treatment Report for 2012, on the outcomes of patients who started treatment in 2012. Methods: The Japan Society of Obstetrics and Gynecology maintains an annual tumor registry, where information on gynecological malignancies from various participating institutions is gathered. The data of patients whose treatment with gynecologic malignancies was initiated in 2017 were analyzed retrospectively. Survival of the patients who started treatment with cervical, endometrial and ovarian cancer in 2012 was analyzed by using the Kaplan‐Meier, log‐rank and Wilcoxon tests. Results: Treatment was initiated in 2017 for 7710 patients with cervical cancer; 11 120 with endometrial cancer; 7029 with ovarian, tubal and peritoneal cancer; 2164 with ovarian borderline tumors; and with the others (213 vulvar cancer, 139 vaginal cancer, 366 uterine sarcoma, 41 uterine adenosarcoma and 131 trophoblastic diseases). This clinicopathological information was summarized as the patient annual report. The 5‐year survival rates of the patients with cervical cancer were 92.9, 75.5, 58.2 and 26.7% for stages I, II, III and IV, respectively. The 5‐year survival rates for the patients with endometrial cancer were 93.6, 85.6, 72.6 and 27.3% for stages I, II, III and IV, respectively. The 5‐year survival rates for the patients with ovarian cancer (surface epithelial‐stromal tumors) were 92.5, 83.5, 49.5 and 30.8% for stages I, II, III and IV, respectively. Conclusion: The annual tumor report is an important survey that provides knowledge on gynecological malignancy trends in Japan. [ABSTRACT FROM AUTHOR]

Objective: To examine the relative contribution of changes in patient demographics and physician management to changes in the cesarean delivery rate in labor among nulliparous women.Methods: We conducted a retrospective cohort study of 485,451 births to nulliparous women who experienced labor at or beyond 35 weeks of gestation in Alberta, Canada, from 1992 to 2018. The data were from a province-wide perinatal database. The primary outcome was cesarean delivery. Multivariate logistic regression and calculation of population attributable risk for identified risk factors were performed.Results: The cesarean delivery rate increased from 12.5% in 1992 to 24% in 2018. The prevalence of maternal risk factors for cesarean delivery such as obesity, maternal age 35 years or older at delivery, and comorbidities increased over the study period. However, this did not account for the increase in cesarean delivery, because the frequency of cesarean delivery increased irrespective of risk status. Additionally, the population-attributable risk for each risk factor was stable across the study period. For example, for maternal age 35 years or older at delivery, the number of cesarean deliveries attributable to this factor (the population-attributable risk) was 0.9 per 100 deliveries in 1992-1998 and 1 per 100 in 2014-2018. The proportion of cesarean deliveries in which nonreassuring fetal status was the indication increased from 30.1% in 1992 to 51.1% in 2018. The absolute rate of cesarean delivery in the second stage of labor increased from 3.1% in 1992 to 5.9% in 2018. This was due to a significant increase, among those who entered the second stage, in cesarean delivery without a trial of forceps, from 2.5% in 1992 to 7.0% in 2018.Conclusion: The observed doubling of the rate of cesarean delivery in labor in first-time mothers was not driven by patient risk factors. Increases in the rate of cesarean delivery for nonreassuring fetal status and decreased operative vaginal deliveries were important factors. [ABSTRACT FROM AUTHOR]

Rural-Urban Differences in Health Care Access Among Women of Reproductive Age: A 10-Year Pooled Analysis MEPS is possibly the most complete source of nationally representative survey data on health care costs, utilization, insurance coverage, and how individuals interact with the health care system. Of interest, rural disparities involving usual care sources, delayed care, and unmet care needs were not observed in this study. [Extracted from the article]

Objective: During the lockdown period, the fear about the risk of infection in hospital has reduced the admission to Emergency Services (ES) with possible negative health effects. We have investigated the changes in the emergency flow occurred during SARS-CoV-2 pandemic in an obstetrics and gynecological ES and the short-term adverse outcomes on women's and reproductive health.Study Design: The study was conducted in the OBGYN ES of the Clinica Mangiagalli, the largest maternity clinic of Milan, Lombardy, Northern Italy. We analyzed retrospectively the records of all women consecutively admitted at the ES from February 23rd to June 24th 2019, and compared them with the admissions during the lockdown executive order from February 23rd to June 23rd, 2020. Patients were assessed in terms of demographic features, presentation times, triage classification (urgent/not urgent), reason for admission and outcome of the visit (discharge/admission to the ward). A total of 9291 data were retrieved from ES files and automation system, 5644 from 2019 and 3647 from 2020. Categorical variables were compared by the chi-square test calculating the p value and computed were percentage changes (with 95 % Confidence interval, CI).Results: During the period February 24 th - May 31 th 2020 the admissions at the ES decreased by 35.4 % (95 % CI-34.1-36.6) compared with the corresponding period in 2019. The reduction was more marked for gynecological complaints (-63.5 %, 95 %CI -60.5 to -66.5): in particular we observed a reduction of admissions for genital infection/cystitis of 75.7 % (95 %CI -71.4 to -80.1). The admission for complaints associated with pregnancy decreased by 28.5 % (95 %CI -27.2 to-29.9). In the index period, five fetal deaths were diagnosed compared with one observed in the reference period in 2019 (chi square computed using as denominator all observed pregnancies = 4.29, p = 0.04). The frequency of admission for elective caesarean section/labor induction increased from 47.5 % in 2019 to 53.6 % in 2020: this difference was statistically significant.Conclusion: The lockdown negatively influenced ES admissions and consequently the women's/reproductive health. As possible short-term consequences, we observed an increase of intrauterine deaths and a decrease of natural births. [ABSTRACT FROM AUTHOR]

Objective: To explore the impact of the COVID-19 pandemic on the mental health of Obstetricians and Gynaecologists.Study Design: A cross-section survey-based study amongst doctors working within Obstetrics and Gynaecology in the United Kingdom.Results: A total of 207 doctors completed the survey. Obstetricians and Gynaecologists reported significantly higher rates of both Major Depressive Disorder (versus, p = 0.023) and Generalised Anxiety Disorder (versus, p = 0.044) as compared to the UK-wide estimates. Sub-group analysis showed that anxiety was more common amongst female doctors as compared to males (versus, p = 0.047). Although the prevalence of GAD was higher amongst registrars compared to their Consultant and/or Senior House Officer counterparts, this was not statistically significant. Respondents felt that the most significant factor for work-related changes to mental health was keeping up to date with frequently changing guidelines and protocols related to COVID-19. Only of respondents felt able to talk to colleagues about their mental health.Conclusions: Key findings include the high prevalence of mental health conditions amongst doctors, demonstration of the persistent taboo that mental health carries within the speciality and the key contributory factors to poor mental health. Further work should be done to assess if changes to the way new and updating guidelines, protocols and pathways are disseminated reduces the impact on the mental health of doctors. With the threat of a second COVID-19 peak looming, now more than ever, it is vital that steps are taken to break the stigmatisation of mental health amongst doctors, encouraging doctors to seek help when required. [ABSTRACT FROM AUTHOR]

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Objective: To evaluate the difference in odds of cesarean delivery in term, singleton, vertex pregnancies between the midwife and obstetrician-led services at the same rural tertiary care center.Methods: A retrospective cohort study of term, singleton, and vertex deliveries in patients without a history of cesarean delivery was performed. Patients self-selected a delivery service. The primary outcome was the odds of cesarean delivery between midwife and obstetrician-led services. After propensity score matching, logistic regression was performed on the matched sample to assess the adjusted odds of cesarean delivery.Results: From January 2015 to December 2017, 1,787 (80.2% of total) deliveries were analyzed with management of 956 (53.5%) by the midwife service and 831 (46.5%) by the obstetrician-led service. The rate of cesarean delivery was 20.7% (n=172) in the obstetrician-led service and 13.1% (n=125) in the midwife service. In the matched sample, the odds of cesarean delivery were lower in the midwife service compared with the obstetrician-led service in unadjusted and adjusted analyses (odds ratio [OR] 0.62, 95% CI 0.47-0.81; adjusted odds ratio [aOR] 0.58, 95% CI 0.44-0.80). Older maternal age (OR 1.02, 95% CI 1.00-1.06; aOR 1.07, 95% CI 1.04-1.10) and higher delivery body mass index (OR 1.06, 95% CI 1.04-1.08; aOR 1.07, 95% CI 1.04-1.09) were associated with higher odds of cesarean delivery. Increased parity was associated with decreased odds of cesarean delivery (OR 0.41, 95% CI 0.31-0.55; aOR 0.35, 95% CI 0.26-0.48). There were no differences in neonatal outcomes.Conclusion: At a single rural tertiary care center, patients on the midwife service have significantly lower adjusted odds of cesarean delivery than patients on the obstetrician-led service. [ABSTRACT FROM AUTHOR]

Objective: To estimate the proportion of obstetrician-gynecologists (ob-gyns) who provided induced abortion in the prior year, disaggregated by surgical and medication methods, and document barriers to provision of medication abortion.Methods: In 2016-2017, we conducted a cross-sectional survey of a national sample of American College of Obstetricians and Gynecologists Fellows and Junior Fellows who were part of the Collaborative Ambulatory Research Network. We sent the survey by email, and mailed nonresponders paper surveys. We performed descriptive statistics, χ tests, and logistic regression analyses.Results: Sixty-seven percent (655/980) of Collaborative Ambulatory Research Network members responded. Ninety-nine percent reported seeing patients of reproductive age, and 72% reported having a patient in the prior year who needed or wanted an abortion. Among those seeing patients of reproductive age, 23.8% (95% CI 20.5%-27.4%) reported performing an induced abortion in the prior year; 10.4% provided surgical and medication abortion, 9.4% surgical only, and 4.0% medication only. In multivariable analysis, physicians practicing in the Midwest (adjusted odds ratio [AOR] 0.31, 95% CI 0.16-0.60) or South (AOR 0.22, 95% CI 0.11-0.42) had lower odds of provision compared with those practicing in the Northeast, whereas those practicing in an urban inner city (AOR 2.71, 95% CI 1.31-5.60) or urban non-inner-city area (AOR 2.89, 95% CI 1.48-5.64 vs midsize towns, rural areas, or military settings) had higher odds of provision. The most common reasons for not providing medication abortion were personal beliefs (34%) and practice restrictions (19%). Among those not providing medication abortion, 28% said they would if they could write a prescription for mifepristone.Conclusion: Compared with the previous national survey in 2008-2009, abortion provision may be increasing among practicing ob-gyns, although important geographic disparities persist. Few provide medication abortion, but uptake might increase if mifepristone could be prescribed. [ABSTRACT FROM AUTHOR]

Objectives: To define current obstetric opinion and clinical practice regarding the prenatal diagnosis of vasa previa in Australia and New Zealand.Methods: A population-based cross-sectional survey of Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists was conducted from April to May, 2016. Descriptive analysis was used to define factors influencing opinion and practice regarding definition of vasa previa, attributable risk factors, and the value of screening.Results: Overall, 453 respondents were included in the study. Two-thirds (304/453; 67.1%) defined vasa previa as exposed fetal vessel(s) running over or within 2 cm of the internal os. A higher proportion of ultrasound specialists (30/65; 46.2%) preferred a broader definition as compared with generalists (115/388; 29.6%; P<0.001). Overall, Fellows were supportive (342/430; 79.5%) of both reporting ultrasound-based risk factors at the 20-week anomaly scan and targeted screening (298/430; 69.3%). Only 77/453 (17.0%) respondents recognized all five "known" risk factors for vasa previa.Conclusions: There was a lack of consensus regarding the definition and diagnosis process for vasa previa. There was also a knowledge gap in risk factors for vasa previa that would inform a targeted screening policy. Nevertheless, support for targeted screening was strong from obstetricians who responded. [ABSTRACT FROM AUTHOR]

Aim: To provide information including the trend of gynecological malignancies in Japan, we hereby present the Annual Patient Report for 2015 and the Annual Treatment Report for 2010 on the outcomes of patients who started treatment in 2010. Methods: The Japan Society of Obstetrics and Gynecology maintains an annual tumor registry where information on gynecological malignancies from various participating institutions is gathered. The data of patients whose treatment was initiated in 2015 were analyzed retrospectively. Survival of the patients who started treatment in 2010 was analyzed by using the Kaplan–Meier, log‐rank and Wilcoxson tests. Results: Treatment was initiated in 2015 for 7527 patients with cervical cancer, 10 119 with endometrial cancer, 6424 with ovarian cancer and 2181 with ovarian borderline tumors. This clinicopathological information was summarized as the Patient Annual Report. Prognoses were analyzed across 4309 patients with cervical cancer, 5054 with endometrial cancer and 3423 with ovarian cancer, whose treatment was initiated in 2010. The 5‐year survival rates of the patients with cervical cancer were 92.1%, 74.2%, 52.0%, and 29.8% for stages I, II, III, and IV, respectively. The 5‐year survival rates for the patients with endometrial cancer were 94.3%, 88.8%, 74.0% and 26.6% for stages I, II, III and IV, respectively. The 5‐year survival rates for the patients with ovarian cancer (surface epithelial‐stromal tumors) were 88.5%, 80.1%, 46.3% and 36.2% for stages I, II, III and IV, respectively. Conclusion: The annual tumor report is an important survey that provides knowledge on gynecological malignancy trends in Japan. [ABSTRACT FROM AUTHOR]

This study describes hospital-based obstetric service losses in rural US counties between 2014 and 2018 overall and by county population and urban adjacency. [ABSTRACT FROM AUTHOR]

Purpose: Fetal lung maturity (FLM) testing has been performed to help direct delivery timing in complex obstetrical conditions. We explored current practice patterns of FLM testing attempting to identify factors affecting its use.Materials and Methods: We distributed a 31-question survey to obstetricians and perinatologists that examined practice characteristics potentially affecting FLM usage. Logistic regression measured associations between these factors and test utilization. Weighted averages were calculated for conditions in which respondents considered FLM testing helpful.Results: Three hundred four surveys were completed. The response rate for respondents actively practicing obstetrics was 52%. The majority of respondents utilize FLM testing; however, 80% reported a decline in use over the past five years with 64% citing "published guidelines" as the reason. Respondents found FLM testing most applicable for poorly dated pregnancies. After an immature FLM test, 44% of respondents administer antenatal corticosteroids in the late-preterm period. None of the factors surveyed were significantly associated with FLM testing use.Conclusion: The majority of respondents use FLM testing although significant factors contributing to its use were not identified. We discover a high frequency of antenatal corticosteroid administration beyond 34 weeks gestational age in response to immature FLM indices that may be an area for future study. [ABSTRACT FROM AUTHOR]

Purpose: Fetal lung maturity (FLM) testing has been performed to help direct delivery timing in complex obstetrical conditions. We explored current practice patterns of FLM testing attempting to identify factors affecting its use.Materials and Methods: We distributed a 31-question survey to obstetricians and perinatologists that examined practice characteristics potentially affecting FLM usage. Logistic regression measured associations between these factors and test utilization. Weighted averages were calculated for conditions in which respondents considered FLM testing helpful.Results: Three hundred four surveys were completed. The response rate for respondents actively practicing obstetrics was 52%. The majority of respondents utilize FLM testing; however, 80% reported a decline in use over the past five years with 64% citing "published guidelines" as the reason. Respondents found FLM testing most applicable for poorly dated pregnancies. After an immature FLM test, 44% of respondents administer antenatal corticosteroids in the late-preterm period. None of the factors surveyed were significantly associated with FLM testing use.Conclusion: The majority of respondents use FLM testing although significant factors contributing to its use were not identified. We discover a high frequency of antenatal corticosteroid administration beyond 34 weeks gestational age in response to immature FLM indices that may be an area for future study. [ABSTRACT FROM AUTHOR]

Objective: Since publication of the Term Breech Trial in 2000 only 15% of term breech presentations is delivered vaginally in the Netherlands. This declined exposure to vaginal breech deliveries (VBD) is a problem for those who still need to be trained. The aim of this study was to evaluate the level of training of the Dutch gynecological residents, and their intentions on guiding VBDs during their careers.Study Design: Via an online questionnaire Dutch residents and starting gynecologists, were asked about their training, exposure and confidence in guiding VBDs during their residency.Main Outcome Measures: Number of VBDs performed, level of entrustment of independent practice in guiding VBDs, courses in guiding VBDs, confidence in guiding VBDs after finishing their residency.Results: The response rate was 64% (N = 294). Thirteen per cent performed less than three VBDs, 15% more than 15. Of sixth year residents 65% has not yet obtained entrustment for personally guiding VBDs. The residents are trained in VBDs at least once during a national mandatory course. Further training is strongly dependent on local hospital policy: 34% are trained every quarter versus 29% who never receive a local training.Conclusion: Our survey showed that more than half of the respondents judge the current residency program to be insufficient for guiding VBDs. This seems to be related to the low overall exposure to VBDs and the lack of quantity and quality of attended courses. [ABSTRACT FROM AUTHOR]

Purpose: To assess the knowledge, practice and attitudes of maternity clinicians regarding congenital cytomegalovirus (CMV). It is the most common congenital infection, and well-recognized cause of neurodevelopmental disability and hearing loss. New consensus recommendations state all pregnant women and health-care providers should be educated about congenital CMV infection and preventive measures.Materials and Methods: An email questionnaire was distributed in October 2015 to specialists, diplomates (general practitioners), and trainees of the Royal Australian New Zealand College of Obstetricians and Gynaecologists (RANZCOG), and Victorian and New South Wales midwives.Results: 774 responded: (37.3% specialists, 17.3% diplomates, 16.8% trainees, 28.6% midwives). Clinicians had variable knowledge of fetal sequelae, transmission routes and prevention. Overall, 30.2% felt confident about discussing CMV in pregnancy: less than 10% of midwives (7.4%) and less than half of specialists (47.1%, p < .0001). Only 8.8% of respondents routinely discussed CMV prevention with pregnant women. The majority (69.3%) responded that professional societies should make practice recommendations, and 88% thought more patient information was needed, preferably leaflets.Conclusions: Australasian maternity clinicians lack confidence and knowledge about congenital CMV. Few (<10%) routinely provide advice on prevention. There is urgent need for clinical guidance and patient information to reduce the burden of disease. [ABSTRACT FROM AUTHOR]

Background: Cancellation of planned surgery impacts substantially on patients and health systems. This study describes the incidence and reasons for cancellation of inpatient surgery in the UK NHS.Methods: We conducted a prospective observational cohort study over 7 consecutive days in March 2017 in 245 NHS hospitals. Occurrences and reasons for previous surgical cancellations were recorded. Using multilevel logistic regression, we identified patient- and hospital-level factors associated with cancellation due to inadequate bed capacity.Results: We analysed data from 14 936 patients undergoing planned surgery. A total of 1499 patients (10.0%) reported previous cancellation for the same procedure; contemporaneous hospital census data indicated that 13.9% patients attending inpatient operations were cancelled on the day of surgery. Non-clinical reasons, predominantly inadequate bed capacity, accounted for a large proportion of previous cancellations. Independent risk factors for cancellation due to inadequate bed capacity included requirement for postoperative critical care [odds ratio (OR)=2.92; 95% confidence interval (CI), 2.12-4.02; P<0.001] and the presence of an emergency department in the treating hospital (OR=4.18; 95% CI, 2.22-7.89; P<0.001). Patients undergoing cancer surgery (OR=0.32; 95% CI, 0.22-0.46; P<0.001), obstetric procedures (OR=0.17; 95% CI, 0.08-0.32; P<0.001), and expedited surgery (OR=0.39; 95% CI, 0.27-0.56; P<0.001) were less likely to be cancelled.Conclusions: A significant proportion of patients presenting for surgery have experienced a previous cancellation for the same procedure. Cancer surgery is relatively protected, but bed capacity, including postoperative critical care requirements, are significant risk factors for previous cancellations. [ABSTRACT FROM AUTHOR]

Low-dose aspirin (LDA) is advocated for women at high-risk of pre-eclampsia, providing a modest, 10%, reduction in risk. Cardiology meta-analyses demonstrate 18% reduction in serious vascular events with LDA. Non-responsiveness to aspirin (sometimes termed aspirin resistance) and variable clinical effectiveness are often attributed to suboptimal adherence. The aim of this review was to identify the scope of adherence assessments in RCTs evaluating aspirin effectiveness in cardiology and obstetrics and discuss the quality of information provided by current methods. We searched MEDLINE, EMBASE and the Cochrane Library, limited to humans and English language, for RCTs evaluating aspirin in cardiology; 14/03/13-13/03/16 and pregnancy 1957-13/03/16. Search terms; 'aspirin', 'acetylsalicylic acid' appearing adjacent to 'myocardial infarction' or 'pregnancy', 'pregnant', 'obstetric' were used. 38% (25/68) of obstetric and 32% (20/62) of cardiology RCTs assessed aspirin adherence and 24% (6/25) and 29% (6/21) of obstetric and cardiology RCTs, respectively, defined acceptable adherence. Semi-quantitative methods (pill counts, medication weighing) prevailed in obstetric RCTs (93%), qualitative methods (interviews, questionnaires) were more frequent in obstetrics (67%). Two obstetric RCTs quantified serum thromboxane B2 and salicylic acid, but no quantitative methods were used in cardiology Aspirin has proven efficacy, but suboptimal adherence is widespread and difficult to accurately quantify. Little is currently known about aspirin adherence in pregnancy. RCTs evaluating aspirin effectiveness show over-reliance on qualitative adherence assessments vulnerable to inherent inaccuracies. Reliable adherence data is important to assess and optimise the clinical effectiveness of LDA. We propose that adherence should be formally assessed in future trials and that development of quantitative assessments may prove valuable for trial protocols. [ABSTRACT FROM AUTHOR]

The Japan Society of Obstetrics and Gynecology collects and analyzes annual data on gynecologic cancers from member institutions. We present the Patient Annual Report for 2014 and the Treatment Annual Report for 2009. Data on 7436 patients with cervical cancer, 9673 with endometrial cancer, 5924 with ovarian cancer, and 1909 with ovarian borderline tumor for whom treatment was initiated in 2014 were summarized in the Patient Annual Report. Stage I accounted for 55.6%, stage II for 22.9%, stage III for 10.2%, and stage IV for 11.2% of all patients with cervical cancer. Stage I accounted for 72.3%, stage II for 6.0%, stage III for 14.1%, and stage IV for 7.7% of all patients with endometrial cancer. Stage I accounted for 43.3%, stage II for 9.1%, stage III for 27.6%, and stage IV for 7.2% of all patients with ovarian cancer. Data on the prognosis of 4126 patients with cervical cancer, 4613 with endometrial cancer, and 3205 with ovarian cancer for whom treatment was initiated in 2009 were analyzed in the Treatment Annual Report. Survival was analyzed by using the Kaplan-Meier method, the log-rank test and the Wilcoxon test. The 5-year overall survival rates for patients with cervical cancer were 92.4% for stage I, 76.7% for stage II, 54.3% for stage III, and 25.2% for stage IV. The equivalent rates for patients with endometrial cancer were 94.6%, 89.4%, 78.3%, and 25.0%, respectively; and those for patients with ovarian cancer (surface epithelial-stromal tumors) were 90.5%, 78.8%, 46.0%, and 25.1%, respectively. [ABSTRACT FROM AUTHOR]

Objective: To create, validate, and use a fertility awareness survey based on current U.S.Data: Design: Cross-sectional study.Setting: Not applicable.Patient(s): Phase 1 included U.S. women ages 18-45; phase 2 included female medical students and obstetrics and gynecology trainees at two urban academic programs.Intervention(s): Survey including demographics, the Fertility & Infertility Treatment Knowledge Score (FIT-KS) instrument, and General Nutrition Knowledge Questionnaire.Main Outcome Measure(s): Knowledge of natural fertility and infertility treatments.Result(s): The FIT-KS was validated through detailed item and validity analyses. In phase 1, 127 women participated; their median age was 31 years, and 43.7% had children. Their mean FIT-KS score was 16.2 ± 3.5 (55.9% correct). In phase 2, 118 medical trainees participated; their median age was 25 years, and 12.4% had children. Their mean FIT-KS score was 18.8 ± 2.1 (64.9% correct), with year of training correlating to a higher score (r=0.40). Participant awareness regarding lifestyle factors varied, but it was particularly low regarding the effects of lubricants. The majority underestimated the spontaneous miscarriage rate and overestimated the fecundability of 40-year-old women. There was general overestimation of success rates for assisted reproductive technologies, particularly among medical trainees.Conclusion(s): The FIT-KS is validated to current U.S. data for use in both general and medical populations as a quick assessment of fertility knowledge. The knowledge gaps demonstrated in this study correlate with national trends in delayed childbearing and time to initiate treatment. For medical trainees, these results raise concerns about the quality of fertility counseling they may be able to offer patients. Greater educational outreach must be undertaken to enhance fertility awareness. [ABSTRACT FROM AUTHOR]

Introduction: We aimed to examine whether cardiotocography (CTG) knowledge, interpretation skills and decision-making measured by a written assessment were associated with size of maternity unit, years of obstetric work experience and healthcare professional background.Material and Methods: A national cross-sectional study in the setting of a CTG teaching intervention involving all 24 maternity units in Denmark. Participants were midwives (n = 1260) and specialists (n = 269) and residents (n = 142) in obstetrics and gynecology who attended a 1-day CTG course and answered a 30-item multiple-choice question test. Associations between mean test score and work conditions were analyzed using multivariable robust regression, in which the three variables were mutually adjusted.Results: Participants from units with > 3000 deliveries/year scored higher on the test than participants from units with < 1000 deliveries/year (3000-3999 deliveries/year: mean difference 0.8, p < 0.0001; > 4000 deliveries/year: mean difference 0.5, p = 0.006). Participants with < 15 years of work experience scored higher than participants with > 15 years of experience (15-20 years of experience: mean difference - 0.6, p = 0.007; > 20 years experience: mean difference - 0.9, p < 0.0001). No differences were detected concerning professional background.Conclusions: CTG knowledge, interpretation skills and decision-making measured by a written assessment were positively associated with working in large maternity units and having < 15 years of obstetric work experience. This might indicate a challenge in maintaining CTG skills in small units and among experienced staff but could also reflect different levels of motivation, test familiarity and learning culture. Whether the findings are transferable to the clinical setting was not examined. [ABSTRACT FROM AUTHOR]

Objective: To use a geographic information system (GIS) to determine accessibility to health facilities for emergency obstetric and newborn care (EmONC) and compare coverage with that stipulated by UN guidelines (5 EmONC facilities per 500 000 individuals, ≥1 comprehensive).Methods: A cross-sectional study was undertaken of all public facilities providing EmONC in 24 districts of Bangladesh from March to October 2012. Accessibility to each facility was assessed by applying GIS to estimate the proportion of catchment population (comprehensive 500 000; basic 100 000) able to reach the nearest facility within 2 hours and 1 hour of travel time, respectively, by existing road networks.Results: The minimum number of public facilities providing comprehensive and basic EmONC services (1 and 5 per 500 000 individuals, respectively) was reached in 16 and 3 districts, respectively. However, after applying GIS, in no district did 100% of the catchment population have access to these services. A minimum of 75% and 50% of the population had accessibility to comprehensive services in 11 and 5 districts, respectively. For basic services, accessibility was much lower.Conclusion: Assessing only the number of EmONC facilities does not ensure universal coverage; accessibility should be assessed when planning health systems. [ABSTRACT FROM AUTHOR]

Prospective and retrospective cohorts and case-control studies are some of the most important study designs in epidemiology because, under certain assumptions, they can mimic a randomized trial when done well. These assumptions include, but are not limited to, properly accounting for 2 important sources of bias: confounding and selection bias. While not adjusting the causal association for an intermediate variable will yield an unbiased estimate of the exposure-outcome's total causal effect, it is often that obstetricians will want to adjust for an intermediate variable to assess if the intermediate is the underlying driver of the association. Such a practice must be weighed in light of the underlying research question and whether such an adjustment is necessary should be carefully considered. Gestational age is, by far, the most commonly encountered variable in obstetrics that is often mislabeled as a confounder when, in fact, it may be an intermediate. If, indeed, gestational age is an intermediate but if mistakenly labeled as a confounding variable and consequently adjusted in an analysis, the conclusions can be unexpected. The implications of this overadjustment of an intermediate as though it were a confounder can render an otherwise persuasive study downright meaningless. This commentary provides an exposition of confounding bias, collider stratification, and selection biases, with applications in obstetrics and perinatal epidemiology. [ABSTRACT FROM AUTHOR]

Objective: We examined rates of serious maternal complications in relation to severe pre-eclampsia based on the delivering hospital's annualised volume.Design: Retrospective cohort study.Population and Setting: Singleton deliveries (n = 25 782 235) in 439 hospitals in the USA.Methods: Annualised hospital volume was categorised as 25-500, 501-1000, 1001-2000 and >2000.Main Outcome Measures: Rates of in-hospital maternal death and serious maternal complications, including puerperal cerebrovascular disorders, pulmonary oedema, disseminated intravascular coagulation, acute renal, heart and liver failure, sepsis, haemorrhage and intubation in relation to severe pre-eclampsia. We derived adjusted risk ratio (RR) and 95% confidence interval (CI), from hierarchical Poisson regression models.Results: Severe pre-eclampsia was associated with an 8.7-fold (95% CI 7.6, 10.1) risk of composite maternal complications, with similar RRs across levels of hospital volumes. However, compared with hospitals with low annual volume (<2000), maternal mortality rates in relation to severe pre-eclampsia were lower in high volume hospitals. The rates of serious maternal complications were 410.7 per 10 000 to women who delivered in hospitals with a high rate of severe pre-eclampsia (≥2.12%) and 584.8 per 10 000 to women who delivered in hospitals with low severe pre-eclampsia rates (≤0.41; RR 1.75, 95% CI 1.24, 2.45).Conclusions: While the risks of serious maternal complications in relation to severe pre-eclampsia was similar across hospital delivery volume categories, deaths showed lower rates in large delivery volume hospitals than in smaller volume hospitals. The risk of complications was increased in hospitals with low compared with high severe pre-eclampsia rates.Tweetable Abstract: Hospital volume had little impact on the association between severe pre-eclampsia and maternal complications. [ABSTRACT FROM AUTHOR]

Objective: To assess obstetricians' perceptions surrounding cesarean delivery rates in Turkey.Methods: The present cross-sectional descriptive study was performed between May 1 and June 30, 2016. Practicing obstetricians with contact details known by the researchers and those attending a conference in Turkey were asked to complete a self-administered questionnaire that collected demographic data and information on participants' opinions, beliefs, knowledge, attitudes, and practices related to cesarean delivery.Results: There were 100 obstetricians who responded to the survey. Awareness of high cesarean delivery rates was reported by 96 (96%) participants and 95 (95%) respondents said they were supportive of efforts to reduce it. There were 60 (60%), 83 (83%), and 100 (100%) participants aware of associations between high cesarean delivery rates and increased maternal and infant mortality; increased risk of uterine rupture; and increased risk of placenta previa, placenta accreta, and emergency cesarean hysterectomy, respectively. The most commonly reported reason for high cesarean delivery rates was high compensation costs during medical litigation legal proceedings, reported by all 100 (100%) participants.Conclusion: Participants were generally aware of the risks associated with high cesarean delivery rates. The results suggest that the greatest concern among obstetricians who perform cesarean deliveries was malpractice litigation. [ABSTRACT FROM AUTHOR]

Objectives: Radical pelvic exenteration can be undertaken for locally invasive or recurrent disease in both colorectal and gynaecological malignancies. In the UK this procedure is usually undertaken by the respective surgical specialties who have undergone divergent surgical training. This study describes and compares outcomes between colorectal and gynae-oncological teams following pelvic exenteration for primary and recurrent gynaecological and colorectal cancers in a single-centre multi-disciplinary team.Method: A retrospective review of consecutive pelvic exenteration patients undertaken over a nine-year period in a tertiary referral centre. Analyses comparing short- and long-term morbidity and mortality outcomes were undertaken by chi-square test for categorical variables and Mann-Whitney U for continuous variables. Cumulative survival rates were calculated according to the Kaplan-Meier method and factors associated with recurrence and survival determined using a Cox regression model.Results: Thirty-four exenterations were undertaken; fourteen colorectal and twenty gynae-oncological. Morbidity was seen in 50% of colorectal and 75% of gynae-oncological patients. Recurrence was seen earlier and with greater frequency in the gynaeoncology group (44.4% and median time 11 months) than the colorectal group (21.4%, median time 41 months; p > 0.05). Survival in the gynae-oncology group was also lower than the colorectal group at 1-year (69.6% vs. 92.9%) and 5-years (58.0% vs. 92.9%; p = 0.115). The majority of gynae-oncological mortality occurred within 3-years of surgery, whilst the majority of mortality in the colorectal group was after 5-years.Conclusion: Long-term patient outcome measures, including disease recurrence and 5-year survival, for colorectal exenteration appear better than for gynaeoncology patients, however, no statistical significant difference exists between short-term outcome measures between specialties. This is likely to be caused by different baseline pathologies and disease pattern influencing longer term prognosis but may also be a function of differing surgical thresholds and patient selection bias between specialties. Peri-operative and short-term morbidity appear equivalent despite divergent surgical backgrounds and training. [ABSTRACT FROM AUTHOR]

Background: Uterine rupture is an obstetric calamity with surgery as its management mainstay. Uterine repair without tubal ligation leaves a uterus that is more prone to repeat rupture while uterine repair with bilateral tubal ligation (BTL) or (sub)total hysterectomy predispose survivors to psychosocial problems like marital disharmony. This study aims to evaluate obstetricians' perspectives on surgical decision making in managing uterine rupture.Methods: A questionnaire-based cross-sectional study of obstetricians at the 46th annual scientific conference of Society of Gynaecology and Obstetrics of Nigeria in 2012. Data was analysed by descriptive and inferential statistics.Results: Seventy-nine out of 110 obstetricians (71.8%) responded to the survey, of which 42 (53.2%) were consultants, 60 (75.9%) practised in government hospitals and 67 (84.8%) in urban hospitals, and all respondents managed women with uterine rupture. Previous cesarean scars and injudicious use of oxytocic are the commonest predisposing causes, and uterine rupture carries very high incidences of maternal and perinatal mortality and morbidity. Uterine repair only was commonly performed by 38 (48.1%) and uterine repair with BTL or (sub) total hysterectomy by 41 (51.9%) respondents. Surgical management is guided mainly by patients' conditions and obstetricians' surgical skills.Conclusion: Obstetricians' distribution in Nigeria leaves rural settings starved of specialist for obstetric emergencies. Caesarean scars are now a rising cause of ruptures. The surgical management of uterine rupture and obstetricians' surgical preferences vary and are case scenario-dependent. Equitable redistribution of obstetricians and deployment of medical doctors to secondary hospitals in rural settings will make obstetric care more readily available and may reduce the prevalence and improve the outcome of uterine rupture. Obstetrician's surgical decision-making should be guided by the prevailing case scenario and the ultimate aim should be to avert fatality and reduce morbidity. [ABSTRACT FROM AUTHOR]

Objective: Prospective registration of clinical trials has been required since 2005. We aimed to assess concordance between registered and reported sample sizes among prospectively registered randomised controlled trials (RCTs) in obstetrics and gynaecology.Design: Analysis of prospectively registered and published data.Setting: Women's health.Sample: Obstetrics and gynaecology RCTs published in eight journals in 2015.Methods: Specialist (Acta Obstet Gynecol Scand, BJOG, Obstet Gynecol and Am J Obstet Gynecol) and general (BMJ, N Engl J Med, JAMA and Lancet) journals were searched from 1 January to 31 December 2015 for main reports of obstetrics and gynaecology RCTs. Their corresponding registries and protocols were sought and data were extracted. Proportions and 95% CI were calculated using exact methods.Main Outcome Measures: Prospective registration of RCT and sample size concordance between RCTs and their registries within those where registration took place before patients were recruited.Results: Of the 75 relevant RCTs, 51 (68%, 95% CI 56-78%, P < 0.001 using a null hypothesis requiring 100% compliance) were prospectively registered, a feature found to be more common in general journals versus specialist journals (21/22 versus 30/53, 95% versus 57%, P = 0.001). Of the 51 prospectively registered RCTs, 31 (61%, 95% CI 46-74%, P = 0.003 using a null hypothesis requiring 40% of studies to achieve their stated sample size) did not reach the target sample size.Conclusions: There are gaps in universal adoption of the prospective trial registration rule. Inability to meet target sample size risks deficiencies in statistical power with unreliability in results.Tweetable Abstract: Only two-thirds of RCTs in women's health are prospectively registered, and over half fail to achieve target sample sizes. [ABSTRACT FROM AUTHOR]

Background: Midwife-led maternity care is shown to be safe for women with low-risk during pregnancy. In Ireland, two midwife-led units (MLUs) were introduced in 2004 when a randomised controlled trial (the MidU study) was performed to compare MLU care with consultant-led care (CLU). Following study completion the two MLUs have remained as a maternity care option in Ireland. The aim of this study was to evaluate maternal and neonatal outcomes and transfer rates during six years in the larger of the MLU sites.Methods: MLU data for the six years 2008-2013 were retrospectively analysed, following ethical approval. Rates of transfer, reasons for transfer, mode of birth, and maternal and fetal outcomes were assessed. Linear-by-Linear Association trend analysis was used for categorical data to evaluate trends over the years and one-way ANOVA was used when comparing continuous variables.Results: During the study period, 3,884 women were registered at the MLU. The antenatal transfer rate was 37.4% and 2,410 women came to labour in the MLU. Throughout labour and birth, 567 women (14.6%) transferred to the CLU, of which 23 were transferred after birth due to need for suturing or postpartum hemorrhage. The most common reasons for intrapartum transfer were meconium stained liquor/abnormal fetal heart rate (30.3%), delayed labour progress in first or second stage (24.9%) and woman's wish for epidural analgesia (15.1%). Of the 1,903 babies born in the MLU, 1,878 (98.7%) were spontaneous vaginal births and 25 (1.3%) were instrumental (ventouse/forceps). Only 25 babies (1.3%) were admitted to neonatal intensive care unit. All spontaneous vaginal births from the MLU registered population, occurring in the study period in both the MLU and CLU settings (n = 2,785), were compared. In the MLU more often 1-2 midwives (90.9% vs 69.7%) cared for the women during birth, more women had three vaginal examinations or fewer (93.6% vs 79.9%) and gave birth in an upright position (standing, squatting or kneeling) (52.0% vs 9.4%), fewer women had an amniotomy (5.9% vs 25.9%) or episiotomy (3.4% vs 9.7%) and more women had a physiological management of third stage of labour (50.9% vs 4.6%).Conclusions: Midwife-led care is a safe option that could be offered to a large proportion of healthy pregnant women. With strict transfer criteria there are very few complications during labour and birth. Maternity units without the option of MLU care should consider its introduction. [ABSTRACT FROM AUTHOR]

Background: Regular monitoring and assessment of performance indicators for emergency obstetric and newborn care can help to identify priorities to improve health services for women and newborns. The aim of this study was to perform a district wide assessment of emergency obstetric and newborn care performance and identify ways for improvement.Methods: Facility assessment of 13 dispensaries, four health centers and one district hospital in a rural district in Tanzania was performed in two data collection periods in 2014. Assessment included a facility walk-through to observe facility infrastructure and interviews with facility in-charges to assess available services, staff and supplies. In addition facility statistics were collected for the year 2013. Results were discussed with district representatives.Results: Approximately 65% of expected births took place in health facilities and 22% of women with complications were treated in facilities expected to provide emergency care. None of the facilities was, however, able to perform at the expected level for emergency obstetric and newborn care since not all required signal functions could be provided. Inadequate availability of essential drugs such as uterotonics, antibiotics and anticonvulsants as well as lack of ability to perform vacuum extraction and blood transfusion limited performance.Conclusions: Performance of emergency obstetric and newborn care in Magu District was not in accordance with expected guidelines and highly influenced by lack of available resources and an insufficiently functioning health care system. Improving assessment approaches, to look beyond the signal functions, can capture weaknesses in the system and will help to understand poor performance and identify locally applicable ways for improvement. [ABSTRACT FROM AUTHOR]

Background: Postpartum hemorrhage is a common obstetric emergency affecting 3 to 5% of deliveries, with significant maternal morbidity and mortality. Effective management of postpartum hemorrhage requires strong teamwork and collaboration. We completed a multidisciplinary in situ postpartum hemorrhage simulation training exercise with structured team debriefing to evaluate hospital protocols, team performance, operational readiness, and real-time identification of system improvements. Our objective was to assess participant comfort with managing obstetric hemorrhage following our multidisciplinary in situ simulation training exercise.Methods: This was a quality improvement project that utilized a comprehensive multidisciplinary in situ postpartum hemorrhage simulation exercise. Participants from the Departments of Obstetrics and Gynecology, Anesthesia, Nursing, Pediatrics, and Transfusion Services completed the training exercise in 16 scenarios run over 2 days. The intervention was a high fidelity, multidisciplinary in situ simulation training to evaluate hospital protocols, team performance, operational readiness, and system improvements. Structured debriefing was conducted with the participants to discuss communication and team functioning. Our main outcome measure was participant self-reported comfort levels for managing postpartum hemorrhage before and after simulation training. A 5-point Likert scale (1 being very uncomfortable and 5 being very comfortable) was used to measure participant comfort. A paired t test was used to assess differences in participant responses before and after the simulation exercise. We also measured the time to prepare simulated blood products and followed the number of postpartum hemorrhage cases before and after the simulation exercise.Results: We trained 113 health care professionals including obstetricians, midwives, residents, anesthesiologists, nurse anesthetists, nurses, and medical assistants. Participants reported a higher comfort level in managing obstetric emergencies and postpartum hemorrhage after simulation training compared to before training. For managing hypertensive emergencies, the post-training mean score was 4.14 compared to a pretraining mean score of 3.88 (p = 0.01, 95% confidence interval [CI] = 0.06-0.47). For shoulder dystocia, the post-training mean score was 4.29 compared to a pretraining mean score of 3.66 (p = 0.001, 95% CI = 0.41-0.88). For postpartum hemorrhage, the post-training mean score was 4.35 compared to pretraining mean score of 3.86 (p = 0.001, 95% CI = 0.36-0.63). We also observed a decrease in the time to prepare simulated blood products over the course of the simulation, and a decreasing trend of postpartum hemorrhage cases, which continued after initiating the postpartum hemorrhage simulation exercise.Discussion: Postpartum hemorrhage remains a leading cause of maternal morbidity and mortality in the United States. Comprehensive hemorrhage protocols have been shown to improve outcomes related to postpartum hemorrhage, and a critical component in these processes include communication, teamwork, and team-based practice/simulation. As medicine becomes increasingly complex, the ability to practice in a safe setting is ever more critical, especially for low-volume, high-stakes events such as postpartum hemorrhage. These events require well-functioning teams and systems coupled with rapid assessment and appropriate clinical action to ensure best patient outcomes. We have shown that a multidisciplinary in situ simulation exercise improves self-reported comfort with managing obstetric emergencies, and is a safe and effective way to practice skills and improve systems processes in the health care setting. [ABSTRACT FROM AUTHOR]

Background: While emergency obstetric and neonatal care (EmONC) is a proxy indicator for monitoring maternal and perinatal mortalities, in Democratic Republic of the Congo (DRC), data on this care is rarely available. In the city of Lubumbashi, the second largest in DRC with an estimated population of 1.5 million, the availability, use and quality of EmONC are not known. This study aimed to assess these elements in Lubumbashi.Methods: This cross-sectional survey was conducted in April and May 2011. Fifty-three of the 180 health facilities that provide maternity care in Lubumbashi were included in this study. Only health facilities with at least six deliveries per month over the course of 2010 were included. The availability, use and quality of EmONC at each level of the health care system were assessed according to the WHO standards.Results: The availability of EmONC in Lubumbashi falls short of WHO standards. In this study, we found one facility providing Comprehensive EmONC (CEmONC) for a catchment area of 918,819 inhabitants. Apart from the tertiary hospital (Sendwe), no other facility provided all the basic emergency obstetric and neonatal care (BEmONC) signal functions. However, all had carried out at least one of the nine signal functions during the 3 months preceding our survey: 73.6% of 53 facilities had administered parenteral antibiotics, 79.2% had systematically offered oxytocics, 39.6% had administered magnesium sulfate, 73.6% had manually evacuated placentas, 81.1% had removed retained placenta products, 54.7% had revived newborns, 35.8% had performed caesarean sections, and 47.2% had performed blood transfusions. Function 6, vaginal delivery assisted by ventouse or forceps, was performed in only two (3.8%) facilities. If this signal function was not taken into account in our assessment of EmONC availability, there would be five facilities providing CEmONC for 918,819 inhabitants, rather than one. In 2010, all the women in the surveyed facilities with obstetric complications delivered in facilities that had carried out at least one signal function in the 3 months before our survey; 7.0% of these women delivered in the facility which provided CEmONC. Mortality due to direct obstetric causes was 3.9% in the health facility that provided CEmONC. The intrapartum mortality was also high in this facility (5.1%). None of the maternity ward managers in any of the facilities surveyed had received training on the EmONC package. Essential supplies and equipment for performing certain EmONC functions were not available in all the surveyed facilities.Conclusion: Audits of maternal and neonatal deaths and near-misses should be established and used as a basis for monitoring the quality of care in Lubumbashi. To reduce maternal and perinatal mortality, it is essential that staff skills regarding EmONC be strengthened, the availability of supplies and equipment be increased, and that care processes be standardized in all health facilities in Lubumbashi. [ABSTRACT FROM AUTHOR]

Background: Most studies examining geographic barriers to maternity care in industrialized countries have focused solely on fetal and neonatal outcomes. We examined the association between rural residence and severe maternal morbidity, in addition to perinatal mortality and morbidity.Methods: We conducted a retrospective population-based cohort study of all women who gave birth in British Columbia, Canada, between Jan. 1, 2005, and Dec. 31, 2010. We compared maternal mortality and severe morbidity (e.g., eclampsia) and adverse perinatal outcomes (e.g., perinatal death) between women residing in areas with moderate to no metropolitan influence (rural) and those living in metropolitan areas or areas with a strong metropolitan influence (urban). We used logistic regression analysis to obtain adjusted odds ratios (ORs) and 95% confidence intervals (CIs).Results: We found a significant association between death or severe maternal morbidity and rural residence (adjusted OR 1.15, 95% CI 1.03-1.28). In particular, women in rural areas had significantly higher rates of eclampsia (adjusted OR 2.70, 95% CI 1.79-4.08), obstetric embolism (adjusted OR 2.16, 95% CI 1.14-4.07) and uterine rupture or dehiscence (adjusted OR 1.96, 95% CI 1.42-2.72) than women in urban areas. Perinatal mortality did not differ significantly between the study groups. Infants in rural areas were more likely than those in urban areas to have a severe neonatal morbidity (adjusted OR 1.14, 95% CI 1.02-1.29), to be born preterm (adjusted OR 1.06, 95% CI 1.01-1.11), to have an Apgar score of less than 7 at 5 minutes (adjusted OR 1.24, 95% CI 1.13-1.31) and to be large for gestational age (adjusted OR 1.14, 95% CI 1.10-1.19). They were less likely to be small for gestational age (adjusted OR 0.90, 95% CI 0.85-0.95) and to be admitted to an neonatal intensive care unit (NICU) (adjusted OR 0.36, 95% CI 0.33-0.38) compared with infants in urban areas.Interpretation: Compared with women in urban areas, those in rural areas had higher rates of severe maternal morbidity and severe neonatal morbidity, and a lower rate of NICU admission. Maternity care providers in rural regions need to be aware of potentially life-threatening maternal and perinatal complications requiring advanced obstetric and neonatal care. [ABSTRACT FROM AUTHOR]

Study Objectives: Obstetric anesthesiologists commonly care for high-risk obstetric patients. However, it is unclear how obstetricians refer these patients for anesthetic evaluation and whether obstetric anesthesia clinics (OACs) are used. Our study aims were to determine the availability and characteristics of OACs at US academic obstetric centers and to evaluate how high-risk patients are referred for anesthetic evaluation.Design: This is a survey study design.Setting: University of Virginia Center for Survey Research.Intervention: A survey questionnaire was constructed and electronically mailed to obstetric anesthesia directors based at hospitals with accredited anesthesia residency programs.Measurement: One hundred thirteen obstetric anesthesia directors were contacted. We asked questions about the presence and operational characteristics of OACs. These characteristics were compared between hospitals with high, medium, and low annual delivery volumes. We also inquired about how high-risk patients are referred for anesthetic evaluation. Frequencies were compared using Fisher test, with P< .05 considered as statistically significant.Main Results: The survey response rate was 58% (n = 65). Overall, only 25 (38%) respondents indicated that their hospital operated an OAC. The proportion of hospitals with an OAC and OAC operational hours did not significantly vary according to hospital delivery volume. Among hospitals with an OAC, 24% respondents indicated that obstetricians always refer high-risk patients to the OAC. Nearly half of respondents (44%) indicated that high-risk patients usually or sometimes receive their first anesthetic evaluation during the delivery hospitalization.Conclusion: Our findings suggest that, among US academic centers, OACs are uncommon and the referral of high-risk patients for antenatal anesthetic evaluation is inconsistent. These findings suggest that more structured referral processes are needed to ensure that high-risk women receive anesthetic evaluation before labor or delivery. [ABSTRACT FROM AUTHOR]

Background: Estimating the true risk of fetal malformations attributable to the use of medications is difficult and perception of risk by health professionals will impact their counseling and treatment of patients who need medication during pregnancy. The objective of this study was to assess the perception of the teratogenic risk of 9 commonly and 3 rarely prescribed drugs among general practitioners and specialists in obstetrics/gynecology.Methods: All 811 general practitioners in the Region of Southern Denmark and all 502 specialist obstetricians/gynecologists in Denmark as a whole were invited to participate in the study based on an online questionnaire. Medians and interpercentile ranges of the perceived background risk and perceived risks for each of the drugs were included in the questionnaire.Results: One hundred forty three (18 %) general practitioners and 138 (27 %) obstetricians/gynecologists participated. Estimates provided by the participants were generally in accordance with current knowledge of drugs with established safety during pregnancy. Perceptions of risks associated with warfarin and retinoid exposure were severely underestimated.Conclusions: Understanding of teratogenic background risk and specific risks associated with in utero exposure to 12 different drugs generally approached the established knowledge. The risk associated with warfarin and retinoid exposure was severely underestimated by both groups of health care professionals, while general practitioners specifically overestimated the risk of sertraline and citalopram to some extent. In Denmark, general practitioners can prescribe antidepressants, and even minor misconceptions of the teratogenic potential of citalopram and sertraline may be of clinical relevance. In Denmark, systemic retinoids can only be prescribed by a dermatologist, and warfarin treatment is only rarely initiated in women of the fertile age without involvement of specialists in internal medicine. Hence, the active knowledge on the teratogenic potential of these drugs is likely to be less accurate among general practitioners and obstetricians/gynecologists; although still of clinical importance since these specialists are largely involved in the counselling of pregnant women. [ABSTRACT FROM AUTHOR]

Objective: To describe Maternal-Fetal Medicine (MFM) physicians' practice patterns for 22-week delivery management.Mehods: Surveyed 750 randomly-sampled members of the Society of Maternal-Fetal Medicine, querying MFMs' practices and policies guiding 22-week delivery management.Results: Three hundred and twenty-five (43%) MFMs responded. Nearly all (87%) would offer induction. Twenty-eight percent would order steroids, and 12% would perform cesarean for a patient desiring resuscitation. Offering induction differed significantly based on the provider's practice setting, region, religious service attendance and political affiliation. In multivariable analyses, political affiliation remained a significant predictor of offering induction (p = 0.03).Conclusions: Most MFMs offer induction for PPROM at 22 weeks. A noteworthy proportion is willing to order steroids and perform cesarean. Personal beliefs and practice characteristics may contribute to these decisions. While little is known about the efficacy of these interventions at 22 weeks, some MFMs will offer obstetrical intervention if resuscitation is intended. [ABSTRACT FROM AUTHOR]

Background: The ability to obtain genetic information can now be accomplished in far greater detail, and more quickly than in the past. It is important to understand obstetrician-gynecologists' (ob-gyns) screening practices as these changes occur.Methods: Cross-sectional survey was performed by mailing paper surveys to Fellows of the American College of Obstetricians and Gynecologists and a subset of Fellows who belong to the Collaborative Ambulatory Research Network (CARN).Results: Response rates were 57% for the CARN network. Almost all responders (92%) offer population-based genetic screening in the prenatal period and almost all (93%) conduct counseling prior to the provision of genetic testing. Almost all (92%) counsel patients when the result is positive, with 46% being the primary counselor and 55% calling the patient themselves. When results are negative, 73% counsel with 58% indicating they are the primary counselor and 17% call patients themselves. A total of 72% have received continuing medical education (CME) on genetics within 5 years, with 79% receiving CME at conferences and 21% receiving CME online.Conclusion: Ob-gyns have a large role in providing patients new genetic screening technologies. This role requires a significant knowledge base, some of which can be obtained by online modules; however, our study suggests online education is underutilized as a means for CME on genetic screening among ob-gyns. [ABSTRACT FROM AUTHOR]

Objective: The Illinois Department of Public Health mandated that all clinicians who provide care to obstetric patients participate in the Illinois Obstetric Hemorrhage Project. The aim of the current report is to describe change in knowledge among providers engaged in the project, as assessed by pre- and post-tests.Methods: The project, implemented 2008 to 2010, included four components: a written 25-item multiple-choice examination (pre-test), a didactic lecture, skill stations (for teaching blood loss estimation), and a simulation drill and debriefing. Participants completed a post-test 6 months later. Pre- and post-test examination scores were compared.Results: Data from 95 hospitals are included in this analysis (9456 paired test results). The proportion of participants who scored ≥88% correct answers increased from 10.9% on the pre-test to 49.1% on the post-test (p < 0.0001). Registered nurses made greater improvements in test scores than anesthesia and obstetric providers (p < 0.0001).Conclusions: The Illinois Obstetric Hemorrhage Project was successful in improving knowledge of obstetric hemorrhage in a large number of providers with different expertise and experience levels. Further long-term study is essential to determine whether the skills acquired during the Project contribute to improved obstetric hemorrhage outcomes for the women of Illinois. [ABSTRACT FROM AUTHOR]

Objective: To determine provider awareness of the College of American Pathologists (CAP) recommended guidelines for examination of placenta and evaluate the Obstetrician -Gynecologist's perception of the clinical utility of placenta pathology reports.Study Design: An anonymous survey of Obstetrician Gynecologists who attended the national conference of The Central Association of Obstetricians and Gynecologists (CAOG) in 2013 assessing their knowledge of the CAP guidelines and utilization of information obtained from pathology reports. Chi-square or Fisher's exact test were used to evaluate association between specialists and non-specialist providers as related to survey questions and multivariable logistic regression used to explore factors associated with utilization and awareness of the guidelines.Results: A total of 218 providers attended the conference and 111 surveys were completed. Only 36% of participants were aware of the CAP guidelines for pathologic examination of the placenta. The odds that a physician with more than 15 years of experience will send a placenta for examination was 0.210 times that of physicians with less than 15 years of experience (CI 0.084, 0.521). The odds for awareness of the CAP guideline among subspecialists who participated in the study were 3.630 times the odds for non-specialist (CI 1.44, 9.147). In addition, the odds of sending a placenta for those physicians in a community hospital are 0.300 times that of physicians in a University hospital (CI 0.110, 0.820). The presence of a pathologist skilled in obstetrics and gynecology did not seem to affect awareness of the CAP guidelines, perception of the usefulness of the guidelines and likelihood of sending a placenta for examination. Only 21% of participants reported understanding the nomenclature used in pathology reports "all the time". Participants ranked the explanation of adverse pregnancy outcome as the most useful clinical application of placenta pathologic examination and most advocated for continued placental pathologic examination.Conclusion: Most of the participants in this study were not aware of the CAP guidelines. The study also revealed deficits in understanding the nomenclature on pathology reports even though providers overall recognized the clinical utility of pathologic examination of the placenta. This emphasizes the importance of actively incorporating the concept of pathologic changes of the placenta into the curriculum for training obstetrician gynecologists and pathologists and for institutions to streamline policies centered on pathologic examination of the placenta. [ABSTRACT FROM AUTHOR]

Introduction: To evaluate differences between consultants of different disciplines in the prenatal prediction of the type of postnatal surgical closure of an omphalocele.Material and Methods: Twenty-one images of prenatally detected omphaloceles prior to 24 weeks of gestation were included. A standardized form provided known prenatal information and an ultrasound image for each case. Nineteen consultants were asked to assess the probability of primary closure of an omphalocele and to state which information was the most important for their assessment.Results: Primary closure (13/21 images) was predicted correctly in 5/13 images. The number of correct predictions per image ranged from 63 to 89%. The type of closure was predicted correctly in 7/8 images of cases which were not closed primarily, ranging from 58 to 84% correct predictions per image. There was no significant difference between consultants of different disciplines. Individual accuracy ranged from 10 to 62%. The consultants regarded omphalocele content as the most important information (34%) for counseling.Discussion: The consultants did not differ in their prenatal judgment of the primary closure of an omphalocele. The consultants tended to be too negative in their assessment, since 75% assessed the probability of primary closure overall to be <60%, whereas 62% of the cases were primarily closed. Omphalocele content was the most important information for the consultants' judgment. [ABSTRACT FROM AUTHOR]

Objective: To compare racial and ethnic differences between obstetrician-gynecologists (ob-gyns) and other large groups of adult medical specialists who provide the predominant care of women. Whether physician diversity influences their practice locations in underserved areas was also sought.Methods: This cross-sectional study reports an analysis of U.S. national data about racial and ethnic characteristics, gender, and specialty (obstetrics and gynecology, general internal medicine, family medicine, emergency medicine) of 190,379 physicians who came from three resources (Association of American Medical Colleges Student Records System, Association of American Medical Colleges Minority Physicians Database, American Medical Association Physician Masterfile). Underserved locations were identified as being rural, having 20% or more of the population living in poverty or being federally designated as areas of professional shortages or underserved populations. Bivariate measures of associations were performed to study the association between physician race and ethnicity and their practice location.Results: Female physicians in all specialties were more likely than males to be nonwhite, and ob-gyns were most likely to be female (61.9%). Compared with other studied specialists, ob-gyns had the highest proportion of underrepresented minorities (combined, 18.4%), especially black (11.1%) and Hispanic (6.7%) physicians. Underrepresented minority ob-gyns were more likely than white or Asians to practice in federally funded underserved areas or where poverty levels were high. Native Americans, Alaska Natives, and Pacific Islanders were the ob-gyn group with the highest proportion practicing in rural areas.Conclusion: Compared with other adult medical specialists, ob-gyns have a relatively high proportion of black and Hispanic physicians. A higher proportion of underrepresented minority ob-gyns practiced at medically underserved areas. [ABSTRACT FROM AUTHOR]

Objective: To estimate the proportion of obstetric practice web sites in the United States providing information on antenatal influenza and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination.Methods: Using www.healthgrades.com, a national random sample of 1,003 obstetric practice web sites was examined for provision of information on antenatal vaccination and other preventive prenatal health topics. Data were collected for this cross-sectional study between September 25, 2014, and November 12, 2014. χ tests and odds ratios were calculated to determine significance and magnitude of associations between provision of antenatal vaccination information and other practice characteristics.Results: Of 1,003 web sites examined, 229 (22.8%) posted information pertaining to antenatal vaccinations. Only 105 web sites (10.5%) provided up-to-date information about both antenatal influenza and Tdap vaccination. Compared with the proportion posting on antenatal vaccination, significantly more web sites posted on safe foods (40.8%; P<.001), safe medications (36.9%; P<.001), and safe exercise (38.5%; P<.001) during pregnancy. When compared with web sites not mentioning these other prenatal health topics, web sites mentioning these topics were more likely to also mention antenatal vaccination (safe foods: 45.7% compared with 7.1%; odds ratio [OR] 11.07, 95% confidence interval [CI] 7.65-16.01; safe medications: 45.4% compared with 9.6%; OR 7.8, CI 5.58-10.89; safe exercise: 45.9% compared with 8.4%; OR 9.2, CI 6.5-13.03).Conclusion: A majority of obstetric care practice web sites do not provide information on antenatal vaccinations. Obstetric practices should consider using their web sites to provide reliable information on antenatal vaccinations as many already do for other prenatal health topics. [ABSTRACT FROM AUTHOR]

Objectives: Our objectives were to assess physician knowledge of costs of products, tests, and services commonly used by obstetrician/gynecologists (OB/GYNs) and identify those items that could be eliminated without decreasing quality of care by performing a prospective observational pilot study.Methods: An anonymous electronic survey was distributed to 70 OB/GYN providers at Greenville Memorial Hospital. Survey items included common laboratory tests, medications, and clinical services. The survey was used to identify items with high cost for which there were less costly but equally efficacious alternatives. As an educational intervention, grand rounds reviewing the survey results, as well as recommendations that would allow for lean healthcare changes, were conducted. Utilization and cost savings were tracked for a 1-year preintervention and a 1-year postintervention.Results: In total, 50 of 70 providers (71%) completed the survey. Hydrocortisone acetate/pramoxine hydrochloride and dinoprostone vaginal inserts were targeted for intervention. Use of the dinoprostone vaginal insert decreased 50.5% with a savings of $66,500 when comparing the preintervention period with the postintervention period. Use of hydrocortisone acetate/pramoxine hydrochloride decreased 90% with a savings of $92,655. Combined, the decreased use of these products led to a $159,155 cost savings in the 1-year postintervention period.Conclusions: OB/GYN providers at our institution had a poor working knowledge of costs. Through the use of a survey and educational intervention, we demonstrated that simple interventions could lead to high-quality, lean healthcare changes. [ABSTRACT FROM AUTHOR]

Objective: To examine the practices and attitudes of obstetric providers in the state of Michigan on their approach to perinatal oral health.Methods: An online survey was distributed using health care provider databases in the state of Michigan. Descriptive statistics were tabulated and Fisher's Exact Test was used for categorical variables.Results: There were 146 respondents, 80 obstetrician-gynecologist (OB/GYN) and 66 certified nurse midwife (CNM) providers. Eighty percent acknowledged that perinatal oral health is an important consideration for optimal prenatal care, while only 53% reported having questions specific to oral health on their intake documents. Only 35% discussed oral health, 29% performed an oral cavity exam and 42% recommended oral health assessment by a dentist. CNMs were more likely than OB/GYNs to discuss the importance of oral health (48% versus 24%, (p <.05)) and recommend a formal dental assessment (61% versus 26% (p<.05)). These findings demonstrate a dichotomy of care in that obstetric providers recognize the importance of oral health care in pregnancy, but only a minority routinely incorporates these surveillance practices.Conclusion: These data highlight a gap in obstetric services that needs attention through specific educational initiatives and further research endeavors that address health care provider practice and patient barriers. [ABSTRACT FROM AUTHOR]

The author reflects on Carle C. et al's study on the production of scientifically derived universal obstetric early warning score (EWS). The study attempts to evaluate the best variables to use for EWS. He informs that the investigators have utilised data from all primary obstetric sources including the Intensive Care National Audit and Research Centre (ICNARC). According to the researchers, the ICNARC data is the best option for data related to sick obstetric population.

To compare the timing of first hospital antenatal care visit by mothers of Aboriginal and non-Aboriginal infants, and to identify the risk and protective factors associated with timeliness of accessing care, mothers who delivered at Campbelltown hospital between October 2005 and November 2006 were surveyed on the maternity ward. This survey was linked to hospital administrative data. Gestational age at first visit to a hospital-based antenatal clinic was compared for mothers of Aboriginal and non-Aboriginal infants. Risks and protective factors associated with timing of antenatal care were also examined using Cox regression and Kaplan-Meier survival curves. Data on 1520 deliveries were included in this study. Mothers of Aboriginal infants presented slightly later to hospital-based antenatal clinics than mothers of non-Aboriginal infants (median 15.6 weeks versus 14.0 weeks). This difference did not remain after adjustment for all risk and protective factors. The three significant factors remaining were: maternal smoking; not in paid employment; and residence in a disadvantaged suburb. The results may reflect the complex associations that exist between the clustering of disadvantage among families of Aboriginal infants. A multifaceted approach is required to improve the timeliness of hospital-based antenatal care for the mothers of Aboriginal infants. [ABSTRACT FROM AUTHOR]

Introduction The incidence of cesarean section has been rising in the past 50 years. With the increased number of cesarean sections, the number of pregnancies with the previous cesarean section rises as well. The aim of this study was to establish the influence of the previous cesarean section on the development of placental complications: placenta previa, placental abruption and placenta accreta, as well as to determine the influence of the number of previous cesarean sections on the complication development. Material and methods The research was conducted at the Clinic of Gynecology and Obstetrics in Nis covering 10-year-period (from 1995. to 2005.) with 32358 deliveries, 1280 deliveries after a previous cesarean section, 131 cases of placenta previa and 118 cases of placental abruption. The experimental groups was presented by the cases of placenta previa or placental abruption with prior cesarean section in obstetrics history, opposite to the control group having the same conditions but without a cesarean section in medical history. RESULTS The incidence of placenta previa in the control group was 0.33%, opposite to the 1.86% incidence after one cesarean section (p<0.001), 5.49% after two cesarean sections and as high as 14.28% after three cesarean sections in obstetric history. Placental abruption was recorded as placental complication in 0.33% pregnancies in the control group, while its incidence was 1.02% after one cesarean section (p<0.001) and 2.02% in the group with two previous cesarean sections. The difference in the incidence of intrapartal hysterectomy between the group with prior cesarean section (0.86%) and without it (0.006%) shows a high statistical significance (p<0.001). CONCLUSION The previous cesarean section is an important risk factor for the development of placental complications. [ABSTRACT FROM AUTHOR]

The article presents a study which estimates the effect of the number of cycles of oral contraceptives pills (OCP) dispensed per visit on method continuation, pill wastage, use of services, and health care costs. Results indicated that dispensing of a one year supply of OCP cycles to women is associated with higher method continuation and lower costs than dispensing fewer cycles per visit.

Objective: To find out whether there is an association between parity and mortality. Design: Prospective cohort study. Setting: Northern Finland, 1966–2001. Participants and methods: 12 055 women in the two northernmost provinces of Finland were followed up from pregnancy in 1966–2001, the coverage percentage being 96%. The data on age, smoking, body mass index, socioeconomic position, age at menarche and age at first birth were collected during pregnancy, and data on deaths were obtained from the National Cause of Death Statistics, maintained by Statistics Finland. The Cox proportional hazard model was used to estimate relative mortality between parity groups. Results: Total mortality was lowest among the women with 2–4 children (reference group). High parity was associated with an up to twofold risk of mortality from vascular complications, but after adjustment for all background factors, this significance disappeared. Mortality from haemorrhagic stroke was fourfold higher among the women with ≥10 births compared with those of the reference group. No differences in cerebral infarction or total cancer mortality were seen between the groups. Primiparity was associated with increased mortality from accidental death (relative risk 2.6, 95% confidence interval 1.6 to 4.4). Conclusions: High parity was associated with an increased risk of mortality from vascular complications, especially haemorrhagic stroke, and primiparity with an increased risk of accidental death. [ABSTRACT FROM AUTHOR]

This report provides an overview of trends in teen pregnancy in Canada since 1974. In Canada, teen pregnancy rates are calculated as the sum of recorded live births, induced abortions, and miscarriages per 1,000 of the population of females aged 15 to 19. Between 1974, the year Statistics Canada began collecting and disseminating data on teen pregnancy, and 2003, the most recent year for which data is available, the teen pregnancy rate declined from 53.9 to 32.1. The decline was more pronounced among younger teens (15-17) than older teens (18-19). There were considerable variations in rates of teen pregnancy among the Canadian provinces/territories with higher rates occurring in the prairie provinces and territories. Canada, the USA, and England and Wales all saw their combined birth/ abortion rates among women under age 20 decline since 1990 and Canada's rate remains less than half the rate of both the USA and England and Wales. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To estimate the incidence of ectopic pregnancy in Yaounde, the capital of Cameroon (Central Africa). METHODS: In 2000, all women admitted for an ectopic pregnancy to health facilities in the city of Yaounde were systematically enrolled, Sociodemographic information on the women and their reproductive history was collected by questionnaire during a face-to-face interview. Medical and obstetrical data (clinical findings at hospital entry, medical history, type of surgery, and final vital status) were collected from gynecologic and surgical files and admission registers. RESULTS: We recorded 320 cases of ectopic pregnancy in health facilities in the city of Yaounde and we estimated that 40,100 live births occurred during the same study period (January to December 2000). The population-based incidence rate of ectopic pregnancy in the city of Yaounde was 0.79% (95% confidence interval 0.72%, 0.88%) in 2000. Three maternal deaths were recorded giving a mortality rate of 0.94% (95% confidence interval 0.32%, 2.72%). CONCLUSION: The 0.79% ectopic pregnancy incidence rate observed in this African country must be considered a minimum due to probable underestimation. Nevertheless, this rate is lower than that currently observed in industrialized countries. Late diagnosis, low percentage of conservative treatment, and subsequent maternal deaths are important findings that should encourage African gynecologists to promote ectopic pregnancy prevention programs and to improve the care given to women with ectopic pregnancy. [ABSTRACT FROM AUTHOR]