Ob-gyn Physicians Research Articles

Patient Decision Making Surrounding Epidural Use in Labor

Introduction/Objectives: Labor is thought to be one of the most painful experiences in a woman’s life, similar to pain caused by complex regional pain syndromes. Epidural analgesia has been proven to provide excellent pain relief, and many women in the United States choose this during their labor course. The decision to use, or not to use, neuraxial analgesia is complex and multifactorial, and has historically generated debate amongst patients and obstetric providers. In addition, many patients will also change their minds about desiring an epidural in labor during their admission to Labor & Delivery based on various factors encountered. This study aimed to determine the number of patients who change their mind about epidural in labor. We also aimed to characterize the factors involved in patients’ decision about epidural analgesia during labor and to determine if these factors change throughout the labor and delivery course. Methods: This study was a single-center, non-randomized, cross-sectional study that was performed at Loyola University Medical Center in the Labor & Delivery unit. The study population included all full-term nulliparous patients that were admitted to Labor & Delivery for full term labor or induction of labor. Patients were eligible if they were 18 years of age or older, and able to read, speak, and complete the study questionnaire in English. Exclusion criteria included previous vaginal delivery, contraindication to vaginal delivery, no plan to deliver during admission, and contraindication to epidural analgesia. The patients completed one questionnaire about preferences for epidural and influencing factors prior to delivery, and one questionnaire after delivery with similar questions. Demographics were collected, as well as data about complications and details of their labor and delivery course. Results: A total of 199 patients completed the study. The epidural rate was higher in patients who planned to receive it (n = 141/144 or 97.9%) than in patients who did not plan to receive an epidural (n = 49/55 or 89.1%). Further, there was significant discordance between patients’ plans for an epidural and receipt of the medication. That is, only three (1.5%) patients who planned to receive an epidural did not receive one. Conversely, 49 (24.6%) patients who did not plan to receive an epidural received one. Compared to patients who did not plan to receive an epidural, those who planned to receive the medication reported that their OBGYN physician (OR = 3.31, 95% CI: 1.80 – 6.06; p < .001), Anesthesiology physician (OR = 2.73, 95% CI: 1.50 – 4.96; p = .001), and labor nurse (OR = 2.50, 95% CI: 1.38 – 4.53; p =.002) were more important sources of information. Further, when compared to patients who did not plan to receive an epidural, those who planned to receive the medication reported they wanted to be more comfortable during the course of labor (OR = 4.84, 95% CI: 2.50 – 9.39; p < .001), that receiving an epidural would make their labor experience more enjoyable (OR = 27.17, 95% CI: 11.72 – 63.00; p < .001), and that getting an epidural was safe (OR = 5.91, 95% CI: 2.96 – 11.80; p < .001). Conclusions: In conclusion, this study found that the majority of patients in our study population chose to receive an epidural in labor, regardless of their plans at the start of their admission. The most important factors in the decision were discussions with the OBGYN and Anesthesiology physicians. Patients who decided to receive an epidural, despite planning not to, reported that they wanted to be more comfortable during their labor course and that receiving an epidural would make their labor experience more enjoyable.

Attitudes and Likelihood of Outpatient Cervical Ripening via Single Balloon Foley Catheter Among OB/GYN Providers, Nurse Practitioners, and Obstetric Labor & Delivery Nurses

Introduction/Objectives: In certain parts of the United States and other developed nations, cervical ripening using the Foley catheter has already been introduced into the outpatient setting. An approved protocol exists at Loyola University Medical Center (LUMC), however usage is nonexistent. The primary aim of this study was to determine the current level of knowledge and familiarity regarding outpatient cervical ripening among OBGYN physicians and labor and advanced practice nurses at LUMC. The secondary aim of the study was to elucidate willingness to offer outpatient cervical ripening and potential reasons for support and hesitancy of this practice. Methods: We created an 8-question anonymous survey to elucidate the current level of knowledge regarding outpatient cervical ripening and potential reasons that a provider may have in support of and against outpatient cervical ripening. The survey was distributed among General OBGYN attendings, fellows, residents, labor and delivery (LD) and advanced practice (APN) nurses at LUMC. Descriptive statistics and Fisher’s exact test was performed on categorical data. An ordinal logistic regression model was used to compare the odds of being more likely to offer outpatient cervical ripening between attendings and resident physicians and the odds of being familiar with outpatient cervical ripening. Results: 45 obstetric care providers completed the survey (comprising 20 OB/GYN residents, 10 General OB/GYN attendings, 13 LD, and 2 APN nurses). The response rate was 72%. 73% of all respondents had some degree of familiarity with outpatient cervical ripening, while 84% were familiar with the current body of research on this practice. Overall, the willingness to offer outpatient cervical ripening was 55% for the group, with only 11% unwilling. There was no difference in the willingness to offer outpatient cervical ripening between attendings and resident physicians (OR = 1.25, 95% CI: 0.32 – 4.88; p = .75) (Table 1). Major factors that drove willingness to offer were decreased induction to delivery time (77%) and patient convenience (85%). Major factors that drove unwillingness to offer OP cervical ripening were lack of fetal monitoring (66%), increased communication from patients (66%), and additional utilization of clinic resources/time for protocol implementation (66%). Resident physicians were significantly more likely to report familiarity with the current research on outpatient cervical ripening than nurses (OR=5.04; 95% CI: 1.24-20.45; p=.02) and attending physicians (OR=4.13; 95% CI: 1.05-17.78; p=.04). There was no difference in familiarity with research behind the practice between physicians and nurses respondents (p=.85). There was no association between those who reported the level of familiarity with the concept of outpatient cervical ripening and their willingness to offer (OR = 1.52, 95% CI: 0.40 – 5.78; p = .54) (Table 2). Conclusions: Moving preinduction cervical ripening to an outpatient setting is equally efficacious and safe when compared to inpatient cervical ripening. However, despite having an existing protocol for cervical ripening using a Foley Balloon, this practice is not currently utilized at LUMC. Our survey suggests that though physicians and nurses are familiar with the concept and the research behind the practice, there are limiting factors for use. Further education regarding outpatient cervical ripening are essential for increasing practice adoption.

Voices From the Field: Amplifying Clinicians' Perspectives for Black Maternal Equity [ID 2683631

INTRODUCTION: Nationally, Black birthing individuals face a disproportionate burden of maternal mortality and severe maternal morbidity. Although there is growing research interest in tackling these inequities, a significant gap exists in incorporating the insights and perspectives of interprofessional front-line clinicians. This study sought to learn the experiences and viewpoints of physicians, certified nurse-midwives (CNMs), and registered nurses (RNs) to identify strategies for addressing maternal care inequities. METHODS: In collaboration with our community advisory board, we constructed semistructured questions to conduct interviews and focus groups with obstetrical clinicians. Transcripts were coded using NVIVO, utilizing inductive and deductive approaches, and content and narrative analysis to identify themes. Participant consent and IRB exemption status were obtained. RESULTS: We interviewed 20 clinicians: 6 ob-gyn physician interviews, 3 CNMs, and 14 RNs across two focus groups between January and July 2023. Key themes emerged regarding systemic challenges and opportunities. Identified challenges include 1) clinician bias and poor communication, 2) unequal care, 3) patient mistrust, and 4) lack of administrative data. Opportunities for future directions include 1) implementation of clinician training and simulation with an equity lens, 2) standardization of maternal care with safety bundles, 3) incorporation of group prenatal care and expansion of postpartum wraparound services, and 4) disaggregation of clinical operations data by race. CONCLUSION: This study identifies key challenges and opportunities to address the Black maternal health crisis. Our findings inform priorities to guide ACOG's collective action and commitment to eliminating racial inequities that lead to disparate health outcomes.

Evaluating the Accuracy and Utility of Large Language Models in Answering Common Contraception Questions [ID 2683633

INTRODUCTION: Traditional web resources that provide information on contraception produce varied results demanding user synthesis. However, direct answers provided by large language models (LLMs) can offer accessible contraception counseling. This study examines the efficacy of four LLMs, OpenAI's ChatGPT 4.0, OpenAI's ChatGPT 3.5, Google Bard, and Microsoft Bing, in answering common contraception questions. METHODS: Contraception questions and responses in a recent American Academy of Family Physicians (AAFP) review were used as reference text. We presented GPT-4.0, GPT-3.5, Bard, and Bing with six contraception questions from the AAFP text, ensuring no prior chat bias. Response formatting was standardized for analysis. Two ob-gyn physician reviewers (S.J. and A.A.), blinded to the source LLM, assessed responses via a 5-point Likert scale on the following criteria: response specificity, evidence basis, completeness, referrals to outside resources, and avoiding speaking in absolutes. Responses were analyzed using the Kruskal–Wallis test (SAS 9.4). RESULTS: The AAFP review scored highest in response specificity, evidence basis, and completeness. Large language models differed significantly on whether responses were evidence based (P<.0001), made referrals to outside resources (P<.001), or spoke in absolutes (P<.05). Notably, GPT-3.5 and Bard consistently provided referrals across all six questions, outperforming the AAFP text on this criteria. No significant differences were found across LLMs in response specificity or response completeness. CONCLUSION: Despite promising LLM-generated responses, the AAFP review outperformed LLMs in critical areas including evidence basis and completeness. Nonetheless, LLMs, especially GPT-3.5 and Bard, demonstrated strong potential as supplementary resources for reproductive health education.

Sexual harassment, bullying, abuse, and discrimination among obgyn physicians and trainees: a systematic review

Sexual harassment, bullying, abuse, and discrimination among obgyn physicians and trainees: a systematic review

Treating Infertility without Assisted Reproduction Techniques

Reproductive Endocrinology/Infertility, programs today emphasize in vitro fertilization-embryo transfer (IVF-ET), intracytoplasmic sperm injection, and pre-implantation genetic diagnosis. When the infertility specialist begins his/ her career, unfortunately, most are not trained to solve infertility problems by non-expensive means without assisted reproductive technology. Thus, today it becomes more important for the generalist in obstetrics and gynecology to learn the principles of treating infertility using methods that are best suited for most patients which are methods generally reimbursed by third party insurance carriers that will not financially deplete the patients. Unfortunately, during OB-GYN residency the teaching of methods for treating infertility is by rotation through REI practices where the emphasis is on IVF-ET. This review is written for the purpose of providing a basis for those OB-GYN physicians who want to know more about diagnosis and treating infertility, to help their patients conceive without expensive procedures e.g., IVF-ET. The “expert” opinion is not only based on 50 years of extensive clinical experience but will provide the published research studies by the authors that provide at least a good starting point for learning methods of treating infertility. Nevertheless, these suggestions need to be modified by the OB-GYN generalist to conform to their patient population, their findings based on their own experience, and based on the nature of their own practice to determine how much time can be dedicated to treat infertility problems themselves.

Demographics of Physician Associates (PAs) in Obstetrics and Gynecology: Where They Work and How They Compare to Other PAs.

As of 2020, maternal and infant health in the US has worsened. At the same time, the number of health professionals available to manage female health issues is changing; the number of physicians in obstetrics and gynecology (Ob-Gyn) and midwives is decreasing, whereas the number of Ob-Gyn physician associates (PAs) is growing. We analyzed PAs practicing in the Ob-Gyn discipline, drawing on the PA Professional Profile, a database maintained by the National Commission on Certification of PAs. In 2021, there were 1,322 Ob-Gyn PAs (1.2% of all clinically active PAs). This health profession has grown by 66.9% since 2013, when only 792 PAs practiced in this specialty. As of 2021, their median age was 38, and 98.0% were female (70.1% of all PAs were female). The practice setting was between office (54.7%) and hospital (34.0%) employment, with 11.3% described as "other." In 2021, the median annual income of Ob-Gyn PAs was $105,000. With the reduction of obstetrician-gynecologists, the relative growth of PAs in this area of medicine and surgery is a natural part of the solution to the projected obstetrical physician deficit.

Navigating a plethora of progesterone receptors: Comments on the safety/risk of progesterone supplementation in women with a history of breast cancer or at high-risk for developing breast cancer

Progesterone and progestin agonists are potent steroid hormones. There are at least three major types of progesterone receptor (PR) families that interact with and respond to progesterone or progestin ligands. These receptors include ligand-activated transcription factor isoforms (PR-A and PR-B) encoded by the PGR gene, often termed classical or nuclear progesterone receptor (nPR), membrane-spanning progesterone receptor membrane component proteins known as PGRMC1/2, and a large family of progestin/adipoQreceptors or PAQRs (also called membrane PRs or mPRs). Cross-talk between mPRs and nPRs has also been reported. The complexity of progesterone actions via a plethora of diverse receptors warrants careful consideration of the clinical applications of progesterone, which primarily include birth control formulations in young women and hormone replacement therapy following menopause. Herein, we focus on the benefits and risk of progesterone/progestin supplementation. We conclude that progesterone-only supplementation is considered safe for most reproductive-age women. However, women who currently have ER + breast cancer or have had such cancer in the past should not take sex hormones, including progesterone. Women at high-risk for developing breast or ovarian cancer, either due to their family history or known genetic factors (such as BRCA1/2 mutation) or hormonal conditions, should avoid exogenous sex hormones and proceed with caution when considering using natural hormones to mitigate menopausal symptoms and/or improve quality of life after menopause. These individuals are urged to consult with a qualified OB-GYN physician to thoroughly assess the risks and benefits of sex hormone supplementation. As new insights into the homeostatic roles and specificity of highly integrated rapid signaling and nPR actions are revealed, we are hopeful that the benefits of using progesterone use may be fully realized without an increased risk of women’s cancer.

The HPV vaccine: Time for ObGyn physicians to up our game

The HPV vaccine: Time for ObGyn physicians to up our game

Comparing Virtual vs In-Person Immersive Leadership Training for Physicians.

The COVID-19 pandemic caused a disruption of in-person workforce development programs. Our immersive physician-oriented leadership institute suspended in 2020, resumed in 2021 with a virtual program, and in 2022 reconvened in-person training. We used this opportunity to compare the participant experience, including reported knowledge acquisition and ability gains, between these nearly identical curricula delivered in vastly different circumstances and formats. We describe the differences in immersive leadership training implementation and adaptations made for virtual vs in-person engagement of two cohorts of OB-GYN physicians. Data were collected from virtual (n=32) and in-person (n=39) participants via post-session surveys. Quantitative data reported includes participant ratings for knowledge gain and ability gain. Qualitative data were obtained via open-ended feedback questions per session and the overall experience. Knowledge and ability scores indicated strong, statistically significant gains in both formats, with some reported learning gains higher in the virtual training. Qualitative data of participant feedback identified a number of positive themes similar across the in-person and virtual settings, with virtual participants noting how construction of the virtual program produced highly effective experiences and engagement. Constructive or negative feedback of the virtual setting included time constraint issues (eg, a desire for more sessions overall or more time per session) and technical difficulties. Positive comments focused on the effectiveness of the experience in both formats and the surprising ability to connect meaningfully with others, even in a virtual environment. However, there were also many comments clearly supporting the preference for in-person over virtual experiences. Immersive physician leadership training can be effectively delivered via virtual or in-person methods, resulting in significant reported gains of knowledge and skills. These programs provide valuable interpersonal connections and skills to support physician leadership. While both formats are effective, participants clearly prefer in-person leadership development experiences and interpersonal learning.

Effect of Residency Training in Treating Maternal Opioid Use Disorder [ID: 1376984

INTRODUCTION: Buprenorphine treatment for opioid use disorder (OUD) remains substantially underutilized, reflecting a systemic deficit in medical education. Our study assesses the effect of residency training in a prenatal OUD-specific clinic (CARE) on postgraduate ob-gyn physician attitudes, self-perceived competence, and treatment of maternal OUD. METHODS: 2013–2022 graduates from a single obstetrics and gynecology residency program were invited to participate in an online anonymous survey, which collected information on demographics, attitudes, self-perceived competency, and current practice. Answers from participants who graduated before the establishment of CARE in 2018 were compared to those who trained after the establishment of CARE using Fisher's exact, χ2, and Student t tests. A value of P<.05 was considered statistically significant. RESULTS: 55/86 (64%) physicians completed the survey. Compared to graduates without CARE experience (N=30), those with residency experience in CARE (N=25) were significantly more likely to be actively prescribing buprenorphine (24% versus 3%, P=.02) or planning to obtain an X-waiver (24% versus 3%, P=.03). The majority with CARE experience reported feeling comfortable prescribing buprenorphine during pregnancy (92.0% versus 13.3%, P<.001), confident to treat maternal OUD (84% versus 26.7%, P<.001), and able to manage buprenorphine treatment during pregnancy (88% versus 30%, P<.001). Those with experience in CARE reported that residency provided sufficient training to manage maternal OUD without additional X-waiver training (84% versus 10%, P<.001). Institutional review board approval was obtained. CONCLUSION: Prenatal OUD-specific clinics are known to be associated with improved patient outcomes, and may also significantly expand the ability of ob-gyn residents to treat maternal OUD after graduation.

Maternal vaccination against pertussis as part of the national immunization program: a qualitative evaluation among obstetric care providers one year after the implementation in December 2019

BackgroundImmunization of pregnant women with a tetanus-diphtheria-and-acellular-pertussis (Tdap) vaccine is an effective and safe way to protect infants from pertussis before their primary vaccinations. Vaccine uptake among pregnant women is influenced by their care providers’ attitudes toward maternal vaccination. This qualitative study aimed to evaluate the implementation of the maternal Tdap vaccination under the National Immunization Program of the Netherlands from the perspective of obstetric care providers.MethodsIn this qualitative and explorative study, we conducted in-depth interviews by telephone with obstetric care providers who were selected from a pool of respondents (convenience sampling) to a questionnaire in a previous study. The interviews were based on a semi-structured interview guide that covered three aspects of the implementation strategy: providers’ overall experience with the implementation of maternal Tdap vaccination in the Netherlands; implementation logistics and counseling, and pregnant women referrals to municipal Youth Healthcare Centers. The interviews were recorded, pseudonymized and transcribed verbatim. Transcripts were analyzed according to the Thematic Analysis approach by two researchers independently in two phases of iterative coding, categorizing, reviewing and redefining until ultimately, emergent themes regarding maternal Tdap vaccination implementation were identified.ResultsInterviews with 11 midwives and 5 OB-GYN physicians yielded 5 major themes regarding the Tdap vaccination implementation strategy: challenges throughout the implementation process, views on maternal Tdap vaccination, general versus tailored counseling, provider responsibilities in vaccine promotion, and impact of materials for information delivery. Participants indicated that to improve provider attitudes toward Tdap vaccination, its implementation requires clear and transparent information about what is entailed, i.e., what is expected from obstetric care providers, how they can obtain information, and when their actions must be initiated. Participants demanded involvement throughout the implementation planning process. They preferred tailored communication with pregnant women over a generalized approach.ConclusionThis study emphasized the importance of involving all relevant healthcare professionals in planning the implementation of maternal Tdap vaccination. Possible barriers perceived by these professionals should be taken into account in order to improve their attitudes toward vaccination, thus to increase uptake among pregnant women.

Association of Primary Care Physicians’ Individual- and Community-Level Characteristics With Contraceptive Service Provision to Medicaid Beneficiaries

Little is known about primary care physicians who provide contraceptive services to Medicaid beneficiaries. Evaluating this workforce may help explain barriers to accessing these services since contraceptive care access is critical for Medicaid beneficiaries' health. To describe the primary care physician workforce that provides contraceptive services to Medicaid beneficiaries and explore the factors associated with their Medicaid contraceptive service provision. This cross-sectional study, conducted from August 1 to October 10, 2022, used data from the Transformed Medicaid Statistical Information System from 2016 for primary care physicians from 4 specialties (family medicine, internal medicine, obstetrics and gynecology [OBGYN], and pediatrics). The main outcomes were providing intrauterine devices (IUDs) or contraceptive implants to at least 1 Medicaid beneficiary, prescribing hormonal birth control methods (including a pill, patch, or ring) to at least 1 Medicaid beneficiary, the total number of Medicaid beneficiaries provided IUDs or implants, and the total number Medicaid beneficiaries prescribed hormonal birth control methods in 2016. Physician- and community-level factors associated with contraceptive care provision were assessed using multivariate regression methods. In the sample of 251 017 physicians (54% male; mean [SD] age, 49.17 [12.58] years), 28% were international medical graduates (IMGs) and 70% practiced in a state that had expanded Medicaid in 2016. Of the total physicians, 48% prescribed hormonal birth control methods while 10% provided IUDs or implants. For OBGYN physicians, compared with physicians younger than 35 years, being aged 35 to 44 years (odds ratio [OR], 3.51; 95% CI, 2.93-4.21), 45 to 54 years (OR, 3.01; 95% CI, 2.43-3.72), or 55 to 64 years (OR, 2.27; 95% CI, 1.82-2.83) was associated with higher odds of providing IUDs and implants. However, among family medicine physicians, age groups associated with lower odds of providing IUDs or implants were 45 to 54 years (OR, 0.66; 95% CI, 0.55-0.80), 55 to 64 years (OR, 0.51; 95% CI, 0.39-0.65), and 65 years or older (OR, 0.29; 95% CI, 0.19-0.44). Except for those specializing in OBGYN, being an IMG was associated with lower odds of providing hormonal contraceptive service (family medicine IMGs: OR, 0.80 [95% CI, 0.73-0.88]; internal medicine IMGs: OR, 0.85 [95% CI, 0.77-0.93]; and pediatric IMGs: OR, 0.85 [95% CI, 0.78-0.93]). Practicing in a state that expanded Medicaid by 2016 was associated with higher odds of prescribing hormonal contraception for family medicine (OR 1.50; 95% CI, 1.06-2.12) and internal medicine (OR, 1.71; 95% CI, 1.18-2.48) physicians but not for physicians from other specialties. In this cross-sectional study of primary care physicians, physician- and community-level factors, such as specialty, age, and the Medicaid expansion status of their state, were significantly associated with how they provided contraceptive services to Medicaid beneficiaries. However, the existence of associations varied across clinical specialties. Ensuring access to contraception among Medicaid beneficiaries may therefore require policy and program approaches tailored for different physician types.

My Three Pregnancy Losses: A Story Told From an OBGYN Physician Working in Japan

My Three Pregnancy Losses: A Story Told From an OBGYN Physician Working in Japan

Protecting life in a time of war.

Despite centuries of lessons from history, war endures. Across Earth, during nearly every year from the beginning of the twentieth century to present day, over 30 wars have been fought resulting in 187 million casualties, excluding the most recent conflict, which is the impetus for this essay (Timeline of 20th and 21st century wars). We are, sadly, a war-mongering people. The word “war” word infiltrates our vernacular, e.g., the war on poverty, on drugs, on cancer, on COVID, and, apropos, on terror. How did rational approaches to disagreement and conflict evade the world’s progress? Reproductive physicians and scientists are dedicated to safeguard lives and build families. Violence is antithetical to our mission as professionals, and moral integrity as humans. We are deeply concerned for, and stand in unity with, our Ukrainian colleagues—the embryologists, scientists, OBGYN and REI physicians, infertility patients, and all people under siege. Reproductive health services for Ukrainians (as with many other war-torn regions) have collapsed. Deeply disturbing reports have emerged that cite civilian hospitals (including maternity centers) being targeted. Liquid nitrogen supplies are scarce. Pregnant mothers and gestational carriers are at emergent risk of delivering in extremely harsh conditions, cold underground bunkers and refugee queues.

Satisfaction and Shortfall of OB-GYN Physicians and Radiologists

Satisfaction and Shortfall of OB-GYN Physicians and Radiologists

The Ethics of e-Cigarettes for Smoking Cessation: A Global Challenge

"Tobacco smoking is especially harmful for women because, in addition to its effects on mortality and morbidity, it negatively impacts pregnancy, reproductive, and health of the offspring. Data from our work in Romania revealed that pregnant tobacco smokers are seeking information and clinical advice related to e-cigarette use as a tobacco cessation approach. E-cigarette use increased rapidly in the recent years in the US and in other countries, including LMICs. The tobacco control field is deeply divided on how to respond to the increase in e-cigarette use. Additional evidence on the ethical issues related to e-cigarette use and tobacco cessation will inform our mHealth and other pregnancy tobacco cessation interventions and will guide future tobacco control policy direction. The objective of this study is to identify ethical concerns and associated attitudes and perceptions related to e-cigarette use for tobacco cessation during pregnancy among pregnant smokers, their life partners, medical professionals, and other stakeholders. We will interview (N=20) and conduct two focus groups with women who smoke (one focus group, N=10) and women who quit during pregnancy (one focus group, N=10); interview life partners (N=10) of such women; interview ObGyn physicians (N=10) and nurses (N=10); and interview (N=10) and conduct one focus group (N=10) with perinatal educators. Other relevant stakeholders will be also interviewed including the leadership of 2035 Tobacco Free Romania, the national Stop Smoking program, the Pure Air consortium, the Romanian Pneumology Society, the SAMAS NGO focused on maternal and child health and rights, and others. With respect to expected outcomes, the proposed application is anticipated to advance understanding of the smokers’ and other stakeholders’ ethical concerns and associated attitudes and perceptions related to e-cigarettes use for tobacco smoking cessation. The in-depth new knowledge will have a positive impact on the cessation of prenatal and postnatal tobacco smoking and will inform future tobacco control policy directions. Results will be available and will be presented at the time of the conference. This work is based on research partly funded through six NIH-funded projects (grant no. K01TW009654, R21TW010896, 5R21TW010896-02S1, 5R21TW010896-02S2, 1R21HD103039-0, 1R25TW010518-01A1). "

Preventing the primary debulking: An educational initiative to increase rates of salpingectomy at cesarean delivery

<h3>Objectives:</h3> Opportunistic salpingectomy is being performed at higher rates at benign hysterectomy and interval sterilization than at cesarean delivery (CD). The aim of the study was to assess physician practices in offering and performing bilateral salpingectomy (BS) at time of CD after an educational initiative. <h3>Methods:</h3> We conducted a prospective cohort study of OBGYN physicians who perform cesarean deliveries. We compared outcomes before and after an educational initiative, which comprised of a Grand Rounds presentation on the latest data on BS at CD reviewing feasibility, safety, cost effectiveness and surgical techniques. Chart abstraction assessed patient demographics and rates of BS at CD before and after the intervention. Anonymous physician surveys were also administered before and six months after the intervention. Chi-square or Fisher's exact test were used for categorical variables and T-test or ANOVA for continuous variables. The study was powered to detect a difference of 10% between rates of BS at CD (β=0.20). <h3>Results:</h3> There were 370 (14% of all CD) sterilization procedures completed at time of CD during the year prior to our intervention, and 168 (12% of all CD) in the subsequent 6 months. Rates of BS at CD increased from 5.1% to 17% (p<0.0001). Tubal ligation and BS had similar mean estimated blood loss (684 vs 718cc, p=0.45) and total operative time (51 vs 53min, p=0.59). Patients who underwent BS tended to be married (79% vs 59%, p=0.008), white (79% vs 60%, p=0.26), and non-Hispanic (78% vs 59%, p=0.02). When completing a BS, suture ligation and sealing bipolar electrocautery were utilized at similar rates (50% and 50% after the intervention, p=0.53). A total of 51 surveys were completed before the intervention and 43 completed 6 months afterwards (68% and 57% response rates of OBGYN providers who perform CD). Half of the providers who completed the post-intervention survey had attended the Grand Rounds. Provider characteristics were similar between the 2 groups. In the pre-intervention survey, 88% of providers reported offering their patients a salpingectomy at the time of hysterectomy, 86% at time of interval sterilization and only 37% at time of cesarean delivery. After the intervention, more physicians offered BS at CD to their patients considering permanent sterilization (37% vs 56%, p=0.09). Similarly, more providers reported having ever completed a BS at CD (71% vs. 88%, p=0.04). The most common reasons providers listed for not offering BS at CD included increased bleeding, increased operative time, and inexperience. Over 90% of providers reported that they would feel comfortable completing a BS with an electrocautery bipolar device and only 67% by using suture ligation. <h3>Conclusions:</h3> Educational initiatives can increase provider willingness to offer and to complete bilateral salpingectomy at cesarean delivery. Ongoing educational efforts to encourage bilateral salpingectomy may potentially prevent future cases of ovarian cancer.

PrEP University: A Multi-Disciplinary University-Based HIV Prevention Education Program

The introduction of emtricitabine/tenofovir diphosphate (FTC/TDF) as pre-exposure prophylaxis (PrEP) for HIV prevention has raised questions regarding which clinicians will serve as prescribers and how providers will be educated about this HIV prevention strategy. We piloted an HIV Prevention Education Program called PrEP University (PrEP U) to address knowledge gaps in HIV prevention among medical trainees. We examined PrEP awareness and assessed learning as a result of the program, measuring knowledge before and after the lectures with an anonymous 5-question multiple choice test. A total of 198 learners participated in PrEP University, which included 127 first year medical students, and post-graduate trainees in internal medicine (n = 23), family medicine (n = 16), OBGYN (n = 13) and pharmacy (n = 19). Prior to PrEP U, 27% of all participants were not aware of PrEP and an additional 8% were unsure if they had heard of it. Knowledge increased significantly after the education program among trainees in OBGYN (2.3 vs 3.8, p < 0.001), pharmacy (1.4 vs 2.5, p = 0.012) and school of medicine (3.3 vs 4.4, p < 0.001), with a trend seen in family medicine (2.7 vs. 3.7, p = 0.067) and internal medicine (2.7 vs 3.4, p = 0.068). Overall, an HIV Prevention Education Program was successfully administered to nearly 200 participants and resulted in improved knowledge of HIV prevention and PrEP across. Pharmacists and OBGYN physicians are two groups with an expanding role in the use of PrEP. Similar programs at other medical schools should be implemented to ensure that future physicians and pharmacists are comfortable with PrEP prescription.

88. Parent and Provider Views of Using Pharmacies for HPV Vaccination in Adolescents

<h3>Background</h3> West Virginia (WV) has high rates of HPV-related cancers and lagging rates of HPV vaccination. Recent legislation in WV allows pharmacists to administer the HPV vaccine to adolescents if prescribed by a provider. The purpose of this study was to assess parent and provider views about using pharmacies to provide the HPV vaccine to adolescents. <h3>Methods</h3> Pediatric, Family Practice and OBGYN physicians within a single institution that serves rural counties were surveyed regarding HPV vaccination practice, and awareness of using pharmacies for provision. Teaching sessions with providers then reviewed the legislation and the logistics of prescribing the vaccine through a pharmacy. Six months later the same departments were surveyed regarding HPV vaccination practice, pharmacy provision, and perspectives about this pharmacy service. Parents of adolescents age 11-18 were also surveyed. Adolescent vaccination status, gender, and WV county of residence were collected, along with Likert scale questions about usefulness of pharmacy access for vaccination. Provider responses were compared before and after the teaching intervention after six months. Parental responses were compared by adolescent gender and rural/urban county designation. Proportions were compared using Chi square statistics. Institutional review board approval was obtained. <h3>Results</h3> Seventy one physicians completed the initial survey, and 45 completed the six month assessment. Only 22.5% were aware of the pharmacy legislation initially, and 64.4% were aware at six months (p= <.001). Most providers felt that pharmacy access would be beneficial for rural patients initially and at 6 months (69% vs 78%, p=0.31). Providers also felt they would be "Likely" or "Very Likely" to prescribe the vaccine to adolescents through a pharmacy, and this did not change significantly at 6 months (71.8% vs 73.3%, p=0.86). However, at 6 months only 2 providers (both OBGYN) actually reported prescribing the vaccine this way. 121 parents completed the survey, which represented 196 adolescents age 11-18. HPV vaccine completion was not affected by rural/urban county designation, but overall males were less likely to have completed the vaccine (Figure 1). Rural parents lived closer to pharmacies than their primary care providers (Figure 2), but only 16 (13.2%) parents were aware of pharmacy access for the HPV vaccine. Of parents whose adolescents had started or completed the vaccine series, 78.1% felt pharmacy access would have been "Very beneficial", and this did not vary by rural/urban designation. <h3>Conclusions</h3> Pharmacy provision of HPV vaccination is under- utilized. Both parents and physicians had favorable views on using pharmacies for adolescent HPV vaccination series completion.