Investigating socioeconomic disparities of Kangaroo mother care on preterm infant health outcomes

Several studies have been conducted to examine the complicated relationships between various factors that influence Kangaroo mother care (KMC) for preterm infants. However, the extended socio-economic model has not been seen in any of the previous studies that looked into the factors related to KMC and how it affects the health outcomes of babies born before in our study population. This study examines the various dimensions of KMC implementation and its influence on the health outcomes of premature infants. The current cross-sectional study was carried out in South Punjab, Pakistan, covering both private and public KMC units in obstetrics and gynecology departments. The study included a sample size of 719 patients and was conducted during a period covering 21 September 2022 to 14 October 2023. Multinomial logistic regression analysis is employed to ascertain the factors by using SPSS-26 (SPSS Inc., Chicago, IL). The use of folic acid (OR: 1.44; 95% CI: 0.87-3.11) and factor anemia (OR: 8.82; 95% CI: 1.69-14.59) no significantly correlated with better health outcomes, while environmental toxin exposure had a negative impact (OR: 0.90). The findings underscore the need for comprehensive interventions and policies to bridge socioeconomic gaps, ensuring all preterm infants benefit from KMC.

Mainz II urinary diversion in low-resource settings: patient outcomes in women with irreparable fistula in Malawi

BACKGROUND

Obstructed labor leading to a vesicovaginal fistula remains a devastating outcome of childbirth in low-resource countries. Women with an irreparable vesicovaginal fistula may be candidates for a urinary diversion, such as the Mainz II modified ureterosigmoidostomy procedure. Previous reviews state that the procedure should be considered in low-resource countries. However, given the limited duration of postoperative follow-up, these studies do not adequately represent the long-term morbidity and mortality that is likely associated with this procedure. We present data that strongly support avoiding the procedure in low-resource countries.

OBJECTIVE

This study aimed to evaluate the postoperative status of the patient (dead, alive, lost to follow-up) and time to death following the Mainz II procedure.

STUDY DESIGN

This is a case series including 21 patients who underwent a Mainz II urinary diversion from April 2013 to June 2015 for management of irreparable vesicovaginal fistula at the Fistula Care Centre in Lilongwe, Malawi. Patients were seen postoperatively at 3, 6, 9, and 12 months, followed by every 6 to 12 months thereafter. Descriptive statistics were performed to summarize the data.

RESULTS

During the postoperative period, 8 (38.1%; 8/21) patients died, 5 (23.8%; 5/21) were lost to follow-up, and 8 (38.1%; 8/21) are currently alive and followed up at the Fistula Care Centre. We strongly suspect that 7 of the 8 deaths were related to the procedure given that the patients had illnesses that exacerbated the metabolic consequences of the procedure. The eighth patient died after being attacked by robbers. Unfortunately, the exact cause of death could not be determined for these patients. Given that most of the suspected illnesses would be treatable in an otherwise healthy patient, even in this low-resource setting, we surmised that the metabolic compromise from the Mainz II procedure likely contributed to their untimely death. The average time from procedure to death was 58 months, with the earliest death at 10 months and the most recent at 7 years after the procedure.

CONCLUSION

The Mainz II procedure is an option for patients with irreparable fistula. However, it should likely not be performed in low-resource countries given the long-term complications that often cannot be adequately addressed in these settings, leading to significant morbidity and mortality.

Quality framework for remote antenatal care: qualitative study with women, healthcare professionals and system-level stakeholders

BACKGROUND

High-quality antenatal care is important for ensuring optimal birth outcomes and reducing risks of maternal and fetal mortality and morbidity. The COVID-19 pandemic disrupted the usual provision of antenatal care, with much care shifting to remote forms of provision. We aimed to characterise what quality would look like for remote antenatal care from the perspectives of those who use, provide and organise it.

METHODS

This UK-wide study involved interviews and an online survey inviting free-text responses with: those who were or had been pregnant since March 2020; maternity professionals and managers of maternity services and system-level stakeholders. Recruitment used network-based approaches, professional and community networks and purposively selected hospitals. Analysis of interview transcripts was based on the constant comparative method. Free-text survey responses were analysed using a coding framework developed by researchers.

FINDINGS

Participants included 106 pregnant women and 105 healthcare professionals and managers/stakeholders. Analysis enabled generation of a framework of the domains of quality that appear to be most relevant to stakeholders in remote antenatal care: efficiency and timeliness; effectiveness; safety; accessibility; equity and inclusion; person-centredness and choice and continuity. Participants reported that remote care was not straightforwardly positive or negative across these domains. Care that was more transactional in nature was identified as more suitable for remote modalities, but remote care was also seen as having potential to undermine important aspects of trusting relationships and continuity, to amplify or create new forms of structural inequality and to create possible risks to safety.

CONCLUSIONS

This study offers a provisional framework that can help in structuring thinking, policy and practice. By outlining the range of domains relevant to remote antenatal care, this framework is likely to be of value in guiding policy, practice and research.

Mixed Signals: Navigating the Obstetrics and Gynecology Signaling Initiative

OBJECTIVE

There are few published accounts of the obstetrics and gynecology (OBGYN) specialty-specific experience with a formal signaling program. Prior studies examining other medical specialties' experiences with signaling are quantitative, having not examined the complexity of the residency applicant experience by directly engaging applicants; therefore, this study aimed to describe the lived experiences of OBGYN residency applicants who employed a formal signaling program during the 2022-2023 residency application cycle to assist and guide future residency applicants.

DESIGN

A phenomenological approach was chosen to prescribe a common meaning for OBGYN residency applicants' experiences. purposeful sampling was employed to ensure racial, ethnic, and institutional geographic diversity in participant representation. Semi-structured interviews were conducted virtually between April and May 2023.

RESULTS

Twenty-five OBGYN residency applicants participated. Fourteen identified as underrepresented in medicine. Four themes emerged: non-uniform decision-making processes, inconsistent guidance, mental health effect, and signaling reflections. Some themes had associated subthemes. Critical aspects of the applicants' journey were revealed, including decision-making dynamics and reliance on trusted advisors. Applicants described tensions and complexities when navigating signaling strategy in relation to abortion education opportunities in a post-Dobbs era. They also conveyed concerns about inconsistencies in signaling guidance, the emotional toll on well-being, and persistent inequities in the application process. They ultimately made recommendations for future directions, including suggestions for more robust advising and improved signaling execution.

CONCLUSIONS

This study offers a comprehensive exploration of the experiences of OBGYN residency applicants with formal program signaling. To ensure equity and transparency in the residency application process, it is crucial to not only provide OBGYN residency applicants with clear guidance on signaling, but also encourage a standardized approach for its utilization by residency programs.

The effect of rural hospital closures on maternal and infant health

OBJECTIVE

To evaluate the effect of rural hospital closures on infant and maternal health outcomes.

DATA SOURCES AND STUDY SETTING

We used restricted National Vital Statistics System birth and linked birth and infant death data, merged with county-level hospital closures from the Sheps Center for the period 2005-2019.

STUDY DESIGN

We used difference-in-difference and event study methods, employing new estimators that account for staggered treatment timing. Our key outcome variables were prenatal care initiation; birth outcomes (<2500 g; <1500 g; <37 weeks; <28 weeks; 5-min Apgar); delivery outcomes (cesarean, induction, hospital birth); and infant death (<1 year of birth; <=30 days of birth; <=7 days of birth; <= 1 day after birth).

DATA COLLECTION/EXTRACTION METHODS

The analysis covered all births in the United States in rural counties (by rurality: all, most, moderately rural).

PRINCIPAL FINDINGS

We found evidence that fewer individuals delivered in their county of residence after a hospital closure, and this was most pronounced for residents of the most rural counties (29%-52% decline (p < 0.01) in the likelihood of delivering in their residence county). We found that hospital closures worsen prenatal, infant, and delivery outcomes for residents of moderately rural counties but improve those outcomes for those in the most rural counties. In moderately rural counties, low birth weight births increased by 10.4% (p < 0.01). We found suggestive evidence of decreased infant deaths in the most rural counties. This pattern of findings is consistent with closures leading residents of the most rural counties to seek care in a different county and residents of moderately rural counties to seek care at a different hospital in the same county.

CONCLUSIONS

Loss of hospital care has meaningful effects on the rural populations; investigating rural counties in aggregate may miss nuanced differences in the effects on the margin of rurality.

Diagnostic Dilemma Regarding Postpartum Seizure in the Setting of Preeclampsia

This case demonstrates a diagnostic dilemma regarding the management of seizures in the postnatal setting. It seeks to highlight the importance of a thorough exploration of history and risk factors for females presenting with seizures in the postpartum period to ensure appropriate treatment and workup. Preeclampsia (PET) is a hypertensive disorder of pregnancy affecting 2%-8% of pregnancies worldwide. Less than 1% of females with preeclampsia experience eclamptic seizures. However, they are associated with significant mortality and morbidity. The majority of these seizures occur in the third trimester with 80% occurring intrapartum or within 48 hours of delivery. Warning symptoms such as headache, visual disturbances, or epigastric pain are not always present. Eclamptic seizures after the first week postpartum are very rare. Seizures, in general, are triggered by many other organic and nonorganic causes, one of which is neurocysticercosis (NCC) most often caused by Taenia solium. Neurocysticercosis is endemic in sub-Saharan Africa and Southeast Asia. In endemic areas, it accounts for approximately 30% of the cases of adult-onset epilepsy, second only to tuberculosis (TB). This is a case of a 40-year-old para 1 female who experienced a postpartum seizure in the setting of preeclampsia diagnosed in the intrapartum period. She successfully underwent standard treatment for the management of eclampsia. Further workup demonstrated brain lesions suspicious for neurocysticercosis, ultimately prompting diagnosis and appropriate neurological management. Neurocysticercosis is a commonly overlooked etiology in the Australian peripartum healthcare setting. It must be included in the differential diagnosis of patients with new-onset seizures who may be from endemic areas. The diagnosis of neurocysticercosis is based on a combination of clinical findings, exposure history, imaging, and serology.

The virtual reality classroom: a randomized control trial of medical student knowledge of postpartum hemorrhage emergency management

Objective

To investigate the use of a virtual reality learning environment (VRLE) to enhance medical student knowledge of postpartum hemorrhage (PPH) emergency management and insertion of a postpartum balloon.

Methods

A randomized control trial involving medical students from University College Dublin, Ireland. Participants were randomly allocated to the intervention group (VRLE tutorial) or control group (PowerPoint tutorial on the same topic). All participants completed pre-learning experience and post-learning experience surveys. Both groups were timed and assessed on postpartum balloon insertion technique on a model pelvis. The primary outcome was assessment of student knowledge. Secondary outcomes included confidence levels, time taken to complete the task, technique assessment, satisfaction with the learning environment, and side effects of VR.

Results

Both learning experiences significantly (p < 0.001) enhanced student performance on the post-learning experience multiple choice questionnaire, with no difference between the intervention and control groups. In the intervention group, time for task completion was significantly less compared to the control group (1-2 min vs. 2-3 min, p = 0.039). Both learning experiences significantly (p < 0.001) enhanced student confidence, with no significant difference between intervention and control groups. 100% of the students using the VRLE enjoyed the experience, and 82.4% were very likely to recommend use of VRLE in medical education. 94.1% of the students felt the VRLE was beneficial over didactic teaching.

Conclusion

Receiving formal instruction, regardless of format, enhances students' knowledge and confidence of the topic covered. Students who received instruction via the VRLE assembled the postpartum balloon faster than students who received didactic teaching. VR may be beneficial in teaching hands-on procedural skills in obstetrics and gynecology education.

Unmet Reproductive Health Needs of Transgender and Gender Diverse People in Hawai'i: A Qualitative Needs Assessment

The purpose of this study was to assess the reproductive health experiences of transgender and gender diverse people in Hawai'i, identify reproductive health needs that were unmet, and explore opportunities for addressing those needs. This was a qualitative, semi-structured individual interview study. Adults who identified as transgender or gender diverse were interviewed about their experiences accessing reproductive health services, their needs, and their ideas about clinical settings in which to receive reproductive health care services. Interviews were conducted until thematic saturation was reached. Six trans men, 6 trans women, and 4 people who identified as non-binary or genderqueer were interviewed. Negative experiences in health care settings, particularly when seeking reproductive health care services, were common. Participants often had multiple providers and gender-affirming care was often accessed separately from other health care services. Desires for fertility and pregnancy varied widely between participants but were often not addressed at the initiation of gender-affirming care. Finding trans-friendly providers was notably difficult and participants often relied on friends and other members of the transgender community for guidance. Obstetrics and gynecology clinics present a potential opportunity for access to reproductive health services although their gendered environment was concerning for some participants. Transgender and gender diverse people in Hawai'i have access to some reproductive health services but experience stigma in certain settings. There is a need for ongoing improvement in reproductive health care services in Hawai'i to improve access for transgender and gender nonconforming people in Hawai'i.

Posterior Reversible Encephalopathy Syndrome Presenting as Delirium With Psychosis and Agitation in the Postpartum Period

Posterior reversible encephalopathy syndrome (PRES), which was first described in 1996, is a neurologic condition characterized by a combination of clinical and neuroimaging findings. PRES may arise in the context of preeclampsia, eclampsia, renal failure, and sepsis, among other conditions. Neuropsychiatric symptoms of PRES include altered mental status, agitation, and in some cases psychosis. PRES occurring in the postpartum period is understudied, especially with regard to its psychiatric manifestations. We aim to add to the literature a case of PRES associated with psychosis and agitation in a postpartum woman, highlighting clinical implications and offering suggestions for practice. A female in her late 20s, with no significant psychiatric or medical history, presented to the hospital at 29 weeks and one day of gestation following a witnessed seizure. She was found to be hypertensive and hyponatremic, was diagnosed with eclampsia, and underwent an emergent cesarean section due to fetal malpresentation. The next day, the patient developed paranoia with acute agitation, and the psychiatry team diagnosed her with delirium with psychosis/agitation secondary to her underlying medical condition. She required intramuscular medications for agitation, was placed in restraints, and was transferred to the ICU for sedation. Subsequently, CT and MRI scans of her head both indicated that she had developed PRES. The patient's delirium and psychotic behavior resolved after appropriate treatment of her eclampsia. To our knowledge, this case report is the second documented case in the literature, of a patient who presented with PRES characterized by agitation and psychotic features in the postpartum period. Due to the significant overlap in symptoms between delirium and postpartum psychosis, this case highlights the crucial importance of interdisciplinary collaboration for accurate diagnosis and prompt treatment of PRES in the postpartum period. The case also speaks to the importance of differentiating postpartum psychosis associated with a primary psychiatric disorder from delirium arising in postpartum patients with or without a previous psychiatric history.

Enhancing functional recovery following postpartum femoral neuropathy: early neurorehabilitation and multidisciplinary obstetric care

Postpartum femoral neuropathy has a reported incidence of less than 1% and its total recovery time extends up to 6 months to a year. A multidisciplinary approach is vital to rule out permanent disability and to assure a correct diagnosis and earlier rehabilitation. We report a case of a 37-year-old puerperal woman with a history of intrapartum epidural analgesia, who presented post-labor unilateral lower-limb motor weakness and sensory loss, with functional compromise on independent gait. A multidisciplinary team consisting of an anesthesiologist, a physiatrist, a neurologist, and an obstetrician was then established. In the initial physiatry and neurology assessment, the patient reported pain (numerical rating scale 7/10) over the inguinal ligament, lower limb hypoesthesia, and muscle weakness. Femoral neuropathy was suspected. Magnetic resonance imaging ruled out potential complications related to the anesthetic procedure. The patient was then enrolled in a supervised rehabilitation program and, 3 weeks later, electrodiagnostic studies confirmed the initial suspicion. Two months later, the patient had regained lower-limb active range of motion and no pain nor paresthesia was reported. Our case report describes how an early multimodal rehabilitation program within a multidisciplinary framework allows for sooner neuromotor function improvement and activities of daily living independence.

Nutrition Education and Nutrition Knowledge Among Obstetrics and Gynecology Residents

Background: Nutrition in pregnancy is a component of the Council on Resident Education in obstetrics and gynecology core curriculum; however, no studies currently examine adherence to this goal. Objectives: Our objective was to assess obstetrics and gynecology (Ob/Gyn) residents' education and knowledge surrounding nutrition in pregnancy, including (1) amount of dedicated didactic time to and attitudes toward, (2) subjective comfort in counseling patients on, and (3) objective knowledge of pregnancy-related nutrition. Materials and Methods: This is a cross-sectional electronic survey-based study. A 28-item questionnaire was distributed to residents enrolled in Ob/Gyn training programs across the United States in 2022. Results: From 247 Ob/Gyn residency programs, 218 residents across postgraduate years and from geographically diverse locations consented to participation and completed all survey questions. Almost half (48%) of participants reported 0 hours per year of dedicated nutrition-related education, 49% reported 1-2 hours, and 3% reported >2 hours. Most residents (92%) strongly agreed or agreed that education regarding pregnancy-related nutrition guidelines would be useful for clinical practice. However, less than one-third (31%) of residents reported feeling comfortable counseling patients on nutrition in pregnancy. On assessment of residents' objective knowledge of pregnancy-related nutrition, mean percentage of correct responses was 74%. Conclusions: This study identifies a gap in graduate medical education, specifically a disconnect between the recognized impact of nutrition on pregnancy outcomes and residents' ability to confidently and effectively counsel patients on nutrition in pregnancy. Results demonstrate a need to develop curriculum and interventions to educate Ob/Gyn residents about pregnancy-related nutrition.

Building Healthy Babies: A Mixed-Methods Needs Assessment for a Pre-Conception Program in Ontario

OBJECTIVES

The objective of this study was to gather Ontario clinicians' and public members' views on the design of a pre-conception patient education program.

METHODS

In this mixed-methods study, online surveys comprised of rank order, multiple choice, and short answer questions were completed by clinicians and public members. Semi-structured focus groups consisting of 2-6 participants each were then held via videoconference. Demographic variables and survey responses were analyzed quantitatively using descriptive and summary statistics. Descriptive thematic qualitative analysis using the constant comparative method of grounded theory was completed on each transcript to generate themes.

RESULTS

A total of 168 public members and 43 clinicians in Ontario completed surveys, while 11 clinicians and 11 public members participated in the focus groups. A pre-conception program in Ontario was felt to be important. An individual appointment with a primary care provider was the favoured program format per survey responses, whereas a virtual format with an interactive component was preferred among focus group participants. Important topics to include were pre-conception health (infertility, genetic screening, folic acid), prenatal and postpartum counselling (diet, activity, substance use, prenatal care, postpartum course), and medical optimization in pregnancy (high-risk medical conditions, medications, mental health). Both groups emphasized the need to consider accommodations for marginalized populations and various cultures and languages.

CONCLUSION

A standardized pre-conception patient education program is felt to be of high value by Ontario clinicians and public members. A pre-conception program may help improve obstetrical outcomes and decrease rates of major congenital anomalies in Ontario.

Quality and reporting of large-scale improvement programmes: a review of maternity initiatives in the English NHS, 2010-2023

BACKGROUND

Large-scale improvement programmes are a frequent response to quality and safety problems in health systems globally, but have mixed impact. The extent to which they meet criteria for programme quality, particularly in relation to transparency of reporting and evaluation, is unclear.

AIM

To identify large-scale improvement programmes focused on intrapartum care implemented in English National Health Service maternity services in the period 2010-2023, and to conduct a structured quality assessment.

METHODS

We drew on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidance to inform the design and reporting of our study. We identified relevant programmes using multiple search strategies of grey literature, research databases and other sources. Programmes that met a prespecified definition of improvement programme, that focused on intrapartum care and that had a retrievable evaluation report were subject to structured assessment using selected features of programme quality.

RESULTS

We identified 1434 records via databases and other sources. 14 major initiatives in English maternity services could not be quality assessed due to lack of a retrievable evaluation report. Quality assessment of the 15 improvement programmes meeting our criteria for assessment found highly variable quality and reporting. Programme specification was variable and mostly low quality. Only eight reported the evidence base for their interventions. Description of implementation support was poor and none reported customisation for challenged services. None reported reduction of inequalities as an explicit goal. Only seven made use of explicit patient and public involvement practices, and only six explicitly used published theories/models/frameworks to guide implementation. Programmes varied in their reporting of the planning, scope and design of evaluation, with weak designs evident.

CONCLUSIONS

Poor transparency of reporting and weak or absent evaluation undermine large-scale improvement programmes by limiting learning and accountability. This review indicates important targets for improving quality in large-scale programmes.

Global research hotspots and trends on robotic surgery in obstetrics and gynecology: a bibliometric analysis based on VOSviewer

Objective

Over the last two decades, the quantity of papers published in relation to robotic surgery in obstetrics and gynecology has continued to grow globally. However, no bibliometric analysis based on VOSviewer has been performed to evaluate the past and present of global research in the field. In this study, we aimed to analyze the bibliometric characteristics of papers on robotic surgery in obstetrics and gynecology to reveal research hotspots and trends in this field.

Methods

The Web of Science Core Collection was searched for scientific papers on robotic surgery in obstetrics and gynecology published between January 1, 1998 and December 31, 2023. Bibliometric metadata of each selected paper was extracted for analysis. The results were visualized by VOSviewer (version 1.6.18).

Results

A total of 1,430 papers met the inclusion criteria. The United States had the highest total link strengths and contributed the most papers (n = 793). The Mayo Clinic produced the largest number of papers (n = 85), and Professor Pedro T Ramirez contributed the most papers (n = 36). The number of citations ranged from 0 to 295 with a total sum of 29,103. The Journal of Minimally Invasive Gynecology published the most relevant papers (n = 252). Keywords were classified into six clusters based on co-occurrence data, of which cluster 1, cluster 4 and cluster 6 had more main keywords with the largest average publication year.

Conclusions

This is the first VOSviewer-based bibliometric analysis of robotic surgery research in obstetrics and gynecology. The United States was the leading country, and the Journal of Minimally Invasive Gynecology was the most productive journal in the field. Scientists and institutions from around the world should push their boundaries to bring about deep collaboration. The main research topic has always been the use of robotic surgery in the treatment of gynecologic malignancies. More randomized controlled trials need to be conducted to compare surgical outcomes of robotic surgery with other surgical approaches. Robotic sacrocolpopexy for pelvic organ prolapse has become a new research hotspot, and robotic surgery for sentinel lymph node detection in gynecologic malignancies are more potential directions for future research.

Update on sex specific risk factors in cardiovascular disease

Cardiovascular disease (CVD) is the leading cause of death worldwide and accounts for roughly 1 in 5 deaths in the United States. Women in particular face significant disparities in their cardiovascular care when compared to men, both in the diagnosis and treatment of CVD. Sex differences exist in the prevalence and effect of cardiovascular risk factors. For example, women with history of traditional cardiovascular risk factors including hypertension, tobacco use, and diabetes carry a higher risk of major cardiovascular events and mortality when compared to men. These discrepancies in terms of the relative risk of CVD when traditional risk factors are present appear to explain some, but not all, of the observed differences among men and women. Sex-specific cardiovascular disease research-from identification, risk stratification, and treatment-has received increasing recognition in recent years, highlighting the current underestimated association between CVD and a woman's obstetric and reproductive history. In this comprehensive review, sex-specific risk factors unique to women including adverse pregnancy outcomes (APO), such as hypertensive disorders of pregnancy (HDP), gestational diabetes mellitus, preterm delivery, and newborn size for gestational age, as well as premature menarche, menopause and vasomotor symptoms, polycystic ovarian syndrome (PCOS), and infertility will be discussed in full detail and their association with CVD risk. Additional entities including spontaneous coronary artery dissection (SCAD), coronary microvascular disease (CMD), systemic autoimmune disorders, and mental and behavioral health will also be discussed in terms of their prevalence among women and their association with CVD. In this comprehensive review, we will also provide clinicians with a guide to address current knowledge gaps including implementation of a sex-specific patient questionnaire to allow for appropriate risk assessment, stratification, and prevention of CVD in women.

Ayurvedic Herbal Medicines: A Literature Review of Their Applications in Female Reproductive Health

Ayurveda, an ancient holistic and personalized healing system originating from the Indian subcontinent, has been gaining increasing attention as a complementary and alternative medical practice for treating various health conditions, including those related to women's reproductive well-being. This comprehensive literature review examines a wide array of experimental and clinical studies exploring the diverse facets of Ayurvedic interventions in addressing issues such as menstrual irregularities, polycystic ovary syndrome (PCOS), infertility, and menopausal symptoms. The paper specifically focuses on discussing the available data regarding the efficacy of Tulsi (Ocimum tenuiflorum), ashwagandha (Withania somnifera), ginger (Zingiber officinale), cardamom (Elettaria cardamomum), turmeric (Curcuma longa), and Shatavari (Asparagus racemosus), which have traditionally been used in Ayurvedic medicine for centuries. The synthesis of literature not only highlights the potential benefits of these Ayurvedic interventions, but also critically assesses the methodological rigor of existing studies, identifying research gaps, and proposing directions for future investigations. While acknowledging the need for further rigorous research and clinical trials, the review emphasizes the benefits of collaborative and integrative healthcare. This review aims to serve as a valuable resource for healthcare practitioners, researchers, and individuals seeking holistic and natural alternatives for female reproductive health management.

Fetal MRI-Based Mediastinal Shift Angle (MSA) and Percentage Area of Left Ventricle (pALV) as Prognostic Parameters for Congenital Diaphragmatic Hernia

OBJECTIVE

Fetal magnetic resonance imaging (MRI) is broadly used as a method for assessing prognosis in congenital diaphragmatic hernia (CDH). In addition to the extent of lung hypoplasia, determined by measuring the lung volume, cardiac impairment due to pulmonary hypertension and left cardiac hypoplasia is decisive for the prognosis. The percentage area of left ventricle (pALV) describes the percentage of the inner area of the left ventricle in relation to the total area, whereas the mediastinal shift angle (MSA) quantifies the extent of cardiac displacement. The prognostic value of pALV and MSA should be evaluated in terms of survival, the need for extracorporeal membrane oxygenation (ECMO) therapy, and the development of chronic lung disease (CLD).

METHODS

In a total of 122 fetal MRIs, the MSA and pALV were measured retrospectively and complete outcome parameters were determined regarding survival for all 122 subjects, regarding ECMO therapy in 109 cases and about the development of CLD in 78 cases. The prognostic value regarding the endpoints was evaluated using logistic regression and ROC analysis.

RESULTS

The MSA was significantly higher in children who received ECMO therapy (p = 0.0054), as well as in children who developed CLD (p = 0.0018). ROC analysis showed an AUC of 0.68 for ECMO requirement and 0.77 with respect to CLD development. The pALV showed a tendency towards higher levels in children who received ECMO therapy (p = 0.0824). The MSA and the pALV had no significant effect on survival (MSA: p = 0.4293, AUC = 0.56; pALV: p = 0.1134, AUC = 0.57).

CONCLUSIONS

The MSA determined in fetal MRI is a suitable prognostic parameter for ECMO requirement and CLD development in CDH patients and can possibly be used as a supplement to the established parameters.

The Effect of Uncertainty Training on the Improvement of Diagnostic Ability in Chinese Medical Students

Objective

To evaluate the effect of the uncertainty training on improvement of students' diagnostic ability.

Methods

Data were collected on 70 fifth-year medical students enrolled in the Case Discussion courses on Obstetrics and Gynecology in the spring of 2020. Of these students, 36 were in the uncertainty training group and 34 in the control group. The effect of training was evaluated by cognitively diagnostic assessment which mapped exam questions to 4 attributes assessing clinical reasoning and basic science knowledge.

Results

Uncertainty training was able to improve students' ability to use basic science concepts for inference and problem solving, and the ability to integrate complex clinical information to arrive at a diagnosis. But it could not improve students' ability on the basic recall of foundational concepts and the ability to use basic science concepts in clinical reasoning. Medical students could do well in integrating complex clinical information although they didn't recall basic science knowledge well.

Conclusion

Uncertainty training could be used as an effective teaching method in Case Discussion course on Obstetrics and Gynecology. However, students still need to improve their basic knowledge besides the training.

Multivariable risk model for postpartum re-presentation with hypertension: development phase

OBJECTIVES

Postpartum hypertension is one of the leading causes of re-presentation to hospital postpartum and is associated with adverse long-term cardiovascular risk. Postpartum blood pressure monitoring and management interventions have been shown to reduce hospital re-presentation, complications and long-term blood pressure control. Identifying patients at risk can be difficult as 40%-50% present with de novo postpartum hypertension. We aim to develop a risk model for postpartum re-presentation with hypertension using data readily available at the point of discharge.

DESIGN

A case-control study comparing all patients who re-presented to hospital with hypertension within 28 days post partum to a random sample of all deliveries who did not re-present with hypertension. Multivariable analysis identified risk factors and bootstrapping selected variables for inclusion in the model. The area under the receiver operator characteristic curve or C-statistic was used to test the model's discriminative ability.

SETTING

A retrospective review of all deliveries at a tertiary metropolitan hospital in Melbourne, Australia from 1 January 2016 to 30 December 2020.

RESULTS

There were 17 746 deliveries, 72 hypertension re-presentations of which 51.4% presented with de novo postpartum hypertension. 15 variables were considered for the multivariable model. We estimated a maximum of seven factors could be included to avoid overfitting. Bootstrapping selected six factors including pre-eclampsia, gestational hypertension, peak systolic blood pressure in the delivery admission, aspirin prescription and elective caesarean delivery with a C-statistic of 0.90 in a training cohort.

CONCLUSION

The development phase of this risk model builds on the three previously published models and uses factors readily available at the point of delivery admission discharge. Once tested in a validation cohort, this model could be used to identify at risk women for interventions to help prevent hypertension re-presentation and the short-term and long-term complications of postpartum hypertension.

Internal Iliac Artery Ligation in Obstetrics and Gynecology: Surgical Anatomy and Surgical Considerations

The internal iliac artery (IIA) is the main arterial vessel of the pelvis. It supplies the pelvic viscera, pelvic walls, perineum, and gluteal region. In cases of severe obstetrical or gynecologic hemorrhage, IIA ligation can be a lifesaving procedure. Regrettably, IIA ligation has not gained widespread popularity, primarily due to limited surgical training and concerns regarding possible complications, including buttock claudication, impotence, and urinary bladder and rectum necroses. Nowadays, selective arterial embolization or temporary balloon occlusion are increasingly utilized alternatives, which can be applied preoperatively or intraoperatively for threatening severe genital or pelvic bleeding. However, IIA ligation retains its relevance, as the previously described procedures are not always available and have limitations. This article provides a step-by-step guide to the IIA ligation procedure and its possible complications. It also includes a detailed description of the anatomy of the IIA and pelvic arterial anastomoses. This review highlights the importance of a thorough understanding of pelvic anatomy as a prerequisite for safe IIA ligation and posits that training in this procedure should be an integral part of obstetrics and gynecology curricula.

ChatGPT's performance in German OB/GYN exams - paving the way for AI-enhanced medical education and clinical practice

Background

Chat Generative Pre-Trained Transformer (ChatGPT) is an artificial learning and large language model tool developed by OpenAI in 2022. It utilizes deep learning algorithms to process natural language and generate responses, which renders it suitable for conversational interfaces. ChatGPT's potential to transform medical education and clinical practice is currently being explored, but its capabilities and limitations in this domain remain incompletely investigated. The present study aimed to assess ChatGPT's performance in medical knowledge competency for problem assessment in obstetrics and gynecology (OB/GYN).

Methods

Two datasets were established for analysis: questions (1) from OB/GYN course exams at a German university hospital and (2) from the German medical state licensing exams. In order to assess ChatGPT's performance, questions were entered into the chat interface, and responses were documented. A quantitative analysis compared ChatGPT's accuracy with that of medical students for different levels of difficulty and types of questions. Additionally, a qualitative analysis assessed the quality of ChatGPT's responses regarding ease of understanding, conciseness, accuracy, completeness, and relevance. Non-obvious insights generated by ChatGPT were evaluated, and a density index of insights was established in order to quantify the tool's ability to provide students with relevant and concise medical knowledge.

Results

ChatGPT demonstrated consistent and comparable performance across both datasets. It provided correct responses at a rate comparable with that of medical students, thereby indicating its ability to handle a diverse spectrum of questions ranging from general knowledge to complex clinical case presentations. The tool's accuracy was partly affected by question difficulty in the medical state exam dataset. Our qualitative assessment revealed that ChatGPT provided mostly accurate, complete, and relevant answers. ChatGPT additionally provided many non-obvious insights, especially in correctly answered questions, which indicates its potential for enhancing autonomous medical learning.

Conclusion

ChatGPT has promise as a supplementary tool in medical education and clinical practice. Its ability to provide accurate and insightful responses showcases its adaptability to complex clinical scenarios. As AI technologies continue to evolve, ChatGPT and similar tools may contribute to more efficient and personalized learning experiences and assistance for health care providers.

Narrative medicine in clinical internship teaching practice

Objective: To explore the effect on empathy skills of integrating narrative medicine instruction into clinical internship undergraduate medical education.Methods: One hundred clinical undergraduate students who were transferred to gynecology and obstetrics in 2016 were selected as subjects and divided into two groups. The control group adopted the traditional practice teaching mode, while the experimental group adopted a narrative medicine integrated with traditional teaching mode. The impact of the narrative medicine course was evaluated using the Davis Empathy Scale, and the students' acceptance of the course was investigated using a self-developed questionnaire.Results: After completion of the rotation, the empathy scores of the experimental group were higher than those of the control group (p < 0.05). Students in the experimental group rated the integration of narrative medicine into the internship class highly, and most students thought that the narrative medicine course was of great benefit with respect to the humanistic quality of medical teaching.Conclusion: The application of narrative medicine teaching in the clinical practice teaching of obstetrics and gynecology promoted students to improve their empathy ability.

American Indian and Alaskan Native Access to Obstetrics and Gynecology Subspecialists: Findings From a National Mystery Caller Study in the United States

Background A significant disparity exists for American Indian and Alaska Native populations in accessing obstetric and gynecology (OBGYN) subspecialty care, as nearly 43% of individuals do not reside in areas where the Indian Health Service (IHS) provides care. Geographical separation from IHS facilities exacerbates healthcare disparities, particularly regarding access to specialized services. This study aims to create a map illustrating the average driving time from an IHS clinic to OBGYN subspecialists (e.g., gynecologic oncology, maternal-fetal medicine, family planning, urogynecology, pediatric and adolescent gynecology, and reproductive endocrinology and infertility [REI]) and determine the average wait time for appointments with these specialists. Study design A cross-sectional and mystery caller study was conducted using hospital-level data from the IHS and data on women from the 2010 United States Census provided by the US Census Bureau. All US OBGYN subspecialists were identified and mapped. The local distribution of clinics near IHS hospitals was determined, and the nearest OBGYN subspecialist was mapped to IHS hospitals providing women's care services. Thirty-seven OBGYN subspecialists closest to IHS hospitals were contacted to calculate the mean wait time for subspecialty care appointments. Results The median driving time to the closest gynecologic oncology, maternal-fetal medicine, family planning, urogynecology, pediatric and adolescent gynecology, and reproductive endocrinology and infertility OBGYN subspecialist was 214 minutes (interquartile range [IQR] 107-290). The longest drive to see a subspecialist for urogynecology services was over 240 minutes. From the 2010 US Census, we identified 583,574 American Indian and Alaska Native (AI/AN) pediatric, adolescent, and women within a 60-minute drive of an IHS hospital. The mean wait time for a new patient appointment was 13.6 business days (SD ± 2). Conclusions Geographical disparities significantly impact the ability of American Indian and Alaska Native populations to access OBGYN subspecialty care. There was no difference in wait times compared to the national average, though there were significantly longer drive times.

Factors associated with reintegration trajectory following female genital fistula surgery in Uganda

BACKGROUND

A female genital fistula, primarily caused by prolonged obstructed labor or after cesarean delivery in resource-limited countries, affects 500,000 to 2,000,000 women worldwide. Fistula is preventable with timely access to high-quality obstetrical care. Access to surgical repair of a female genital fistula has greatly increased over time. However, research surrounding postrepair reintegration, the process of returning to an individual's normal life, remains limited, and further efforts are needed to understand the factors shaping women's ability to rebuild their relationships and lives following repair.

OBJECTIVE

This study aimed to characterize the 12-month reintegration trajectory after female genital fistula repair by participant sociodemographic and clinical characteristics.

STUDY DESIGN

This study analyzed quantitative survey and medical record data of women (N=60) participating in a longitudinal cohort study assessing recovery after genital fistula repair in Uganda, with baseline and 4 quarterly follow-up assessments in 12 months. The primary outcome of reintegration was assessed using a 19-item postfistula repair reintegration instrument (range, 0-100) where a higher score represents better reintegration. Predictors of interest included parity and living children, quality of life, depressive symptoms at baseline, self-esteem, stigma, trauma, physical symptoms, and social support. We described participant baseline characteristics using means and proportions and estimated a series of mixed-effects linear regression models, including interactions of characteristics with time to understand how these characteristics influence reintegration trajectory in the 12 months after repair.

RESULTS

The participants' physical and psychosocial morbidities at baseline were high; more than 80% of participants reported fistula-related physical symptoms, 82% of participants described their general health as poor, and measures of self-esteem, overall social support, and overall quality of life were low. The mean reintegration score at baseline was 33 (standard deviation, 20), which increased to 78 (standard deviation, 19) at 12 months after fistula repair. The participant sociodemographic characteristics statistically associated with reintegration included any living children (β, 1.08; 95% confidence interval, -0.08 to 2.23). Moreover, psychosocial factors significantly affected reintegration with steeper trajectories for women with depressive symptoms (β, 0.89; 95% confidence interval, 0.02-1.75) or women experiencing internalized stigma (β, 0.05; 95% confidence interval, -0.00 to 0.11) and less steep for those with higher self-esteem (β, -0.11; 95% confidence interval, -0.24 to 0.01), overall social support (β, -0.06; 95% confidence interval, -0.12 to -0.01), and partner support (β, -0.21; 95% confidence interval, -0.35 to -0.07).

CONCLUSION

Understanding the prominent factors associated with differences in reintegration trajectories across the year after genital fistula surgery has the potential to inform interventions that mitigate challenges and improve women's postrepair recovery experiences.

Effect of an electronic medical record nudge to improve quality improvement program tracking of neuraxial catheter replacements in obstetric patients

BACKGROUND

Monitoring complications associated with medical procedures requires reliable and accurate record keeping. Nudge reminders executed by way of electronic medical record (EMR) alerts influence clinician behaviour. We hypothesised that the introduction of an EMR nudge would improve documentation of replaced neuraxial blocks by obstetric anaesthesiologists at our institution.

METHODS

We developed an EMR nudge that would alert the physician to a replaced neuraxial block if two or more neuraxial procedure notes in a single patient encounter were detected. The nudge encouraged physicians to document neuraxial block replacements in our institution's quality improvement database. We assessed the rate of physician adherence to replaced neuraxial block charting prior to the introduction of the nudge (January 2019-September 2019) and after the implementation (October 2019-December 2020).

RESULTS

494 encounters during the chart review period, January 2019-December 2020, required a neuraxial block replacement, representing an actual neuraxial replacement rate of 6.3% prior to the introduction of the nudge in October 2019. This rate was largely unchanged (6.2%) after the introduction of the nudge (0.1% difference, 95% CI: -0.0119 to 0.0099). Prior to the introduction of the nudge, the proportion of correctly charted failed/replaced blocks in our quality improvement database was 80.0%, and after nudge introduction, the rate was 96.2% (p value <0.00001, OR=6.32, 95% CI: 3.15 to 12.66). A p-chart of the monthly adherence rate demonstrated sustained improvement over time.

CONCLUSIONS

EMR nudge technology significantly improved adherence with quality metric monitoring of neuraxial catheter replacement in obstetric patients. The results imply that data collection for quality metric databases of neuraxial block failures and replacements that rely on clinician memory without a nudge are likely under-reporting neuraxial block failures and replacements. This study supports widespread implementation of nudges in EMRs to improve quality metric reporting.

Workplace Violence Toward Doctors Working in Obstetrics and Gynecology Emergency Units in Khartoum North Locality, Sudan: A Cross-Sectional Study

BACKGROUND AND OBJECTIVES

Workplace violence (WPV) is any action, incident, or behavior that deviates from appropriate conduct and results in a person getting assaulted, threatened, harmed, or injured at work. This research aimed at studying the current state of WPV among doctors working in obstetrics and gynecology (OBGYN) emergency departments (EDs) in Khartoum north locality (KNL), Sudan   Methods: A descriptive cross-sectional study that included 128 doctors from six governmental hospitals in KNL. A self-administered questionnaire assessing the prevalence and outcomes of WPV was distributed. The descriptive statistics and frequency tables were generated using the Statistical Package for Social Sciences (SPSS) version 21 (IBM Corp., Armonk, NY).   Results: The respondents' mean age was 28.3±6.6 years (range: 21-70 years). Approximately half of the respondents (49.2%) experienced WPV. Verbal WPV was the most common type (93.3%), followed by physical (10%) and sexual (3.2%) type. Patients' relatives and friends are the most common group to commit WPV (92.9%). Night shifts were the time most WPV (58.6%) took place. The effect of WPV on respondents was mainly psychological (95.8%) compared to physical (4.2%).   Conclusion: WPV prevalence among health care workers (HCWs) working in the OBGYN EDs is alarming with detrimental effects. Evaluating the current state of WPV, outcome, and associated factors will help not only address the current problem but also guide future related research.

Post-hysteroscopy Ruptured Tubo-Ovarian Abscess With Atypical Bacteremia: A Case Report

Hysteroscopies are commonly performed in the diagnosis and treatment of patients with abnormal uterine bleeding. Current research suggests a low rate of all types of complications following hysteroscopies. The rate of infectious complications has been reported as exceptionally low. We present a case of tubo-ovarian abscess with Escherichia coli bacteremia and eventual abscess rupture in a 51-year-old gravida 3, para 2012 (G3P2) woman who underwent a hysteroscopy with concurrent polypectomy. The patient had no risk factors that have historically been attributed to the development of post-hysteroscopy infection, such as a history of pelvic inflammatory disease or endometriosis. The patient also had no known intra-operational complications that might predispose her to infection. Further, the patient's clinical presentation was significantly atypical. Despite having E. coli bacteremia on admission, severe abdominal pain, lack of an adequate response to several days of intravenous broad-spectrum antibiotics, and eventually evidence of abscess rupture, the patient never met clinical criteria for sepsis, including a lack of leukocytosis. This case demonstrates a rare presentation of a rare complication and emphasizes the necessity of clinical vigilance in diagnosing and promptly treating gynecological infectious complications.

Blood Utilization Trends in Obstetrics and Gynecology: A Seven-Year Retrospective Study in a Teaching Hospital in Sikkim, India

INTRODUCTION

Unutilized cross-matched blood due to excess cross-match requisitions results in unnecessary wastage of inventory, time, labor, and financial resources. This retrospective cross-sectional study aims to assess the blood utilization practices in obstetrics/gynecology (OB/GYN) over a period of seven years with respect to "blood utilization indices" and standard recommendations.

MATERIAL AND METHODS

Cross-match requisitions from the OB/GYN Department over a period of seven years (2012-2018) were selected and included in the study using a suitable sampling technique. Patient details were retrieved from the Hospital Information System (HIS) database. The preoperative crossmatch requisitions and blood utilization data were recorded. "Blood utilization indices" and whole blood/component utilization patterns were analyzed.

RESULTS

A total of 894 units of blood were cross-matched for 523 patients included in the study. A total of 305 of these patients were transfused with 445 units. During the initial phase of the study (2012-2014), the average cross-match-to-transfusion ratio (CTR, 6.6), transfusion probability (12.3), transfusion index (0.23), and component utilization (4%) were in marked deviation from recommended "blood utilization indices." This was in contrast with the later phase of the study (2015-2018) wherein the average CTR (1.5), transfusion probability (69.3), transfusion index (1.3), and component utilization (91.8%) were compliant with recommended "blood utilization indices."

CONCLUSION

A progressive improvement in blood utilization practices was observed in the OB/GYN Department during the study period. Awareness campaigns have contributed to the implementation of rational and judicious blood transfusion practices in our center.

Asymptomatic Patient With Incarcerated Gravid Uterus Diagnosed in the Third Trimester: A Case Report of a Rare Potential Obstetric Emergency

Incarcerated gravid uterus (IGU) is a rare condition that occurs when a retropositioned gravid uterus becomes entrapped within the pelvic cavity. Most patients present around the 17th week of pregnancy with symptoms such as pelvic fullness, urinary incontinence, abdominal pain, constipation, and vaginal bleeding. Rarely, patients are asymptomatic throughout pregnancy, leaving IGU undiagnosed and untreated. Here, we present an asymptomatic 26-year-old female who presented at 30 weeks of gestation with severe intrauterine growth retardation (IUGR) on serial obstetric ultrasounds. Further evaluation with ultrasound and MRI revealed an incarcerated uterus. This was complicated by severe fetal IUGR, abnormal biophysical profile, and oligohydramnios. This case highlights the importance of early diagnosis and treatment of IGU in order to prevent complications associated with the condition. Clinicians should be aware that, although uncommon, patients with IGU may be asymptomatic and that diagnosis should depend primarily on imaging findings rather than symptoms.

Assessing the Readability of Online Patient Education Materials in Obstetrics and Gynecology Using Traditional Measures: Comparative Analysis and Limitations

BACKGROUND

Patient education materials (PEMs) can be vital sources of information for the general population. However, despite American Medical Association (AMA) and National Institutes of Health (NIH) recommendations to make PEMs easier to read for patients with low health literacy, they often do not adhere to these recommendations. The readability of online PEMs in the obstetrics and gynecology (OB/GYN) field, in particular, has not been thoroughly investigated.

OBJECTIVE

The study sampled online OB/GYN PEMs and aimed to examine (1) agreeability across traditional readability measures (TRMs), (2) adherence of online PEMs to AMA and NIH recommendations, and (3) whether the readability level of online PEMs varied by web-based source and medical topic. This study is not a scoping review, rather, it focused on scoring the readability of OB/GYN PEMs using the traditional measures to add empirical evidence to the literature.

METHODS

A total of 1576 online OB/GYN PEMs were collected via 3 major search engines. In total 93 were excluded due to shorter content (less than 100 words), yielding 1483 PEMs for analysis. Each PEM was scored by 4 TRMs, including Flesch-Kincaid grade level, Gunning fog index, Simple Measure of Gobbledygook, and the Dale-Chall. The PEMs were categorized based on publication source and medical topic by 2 research team members. The readability scores of the categories were compared statistically.

RESULTS

Results indicated that the 4 TRMs did not agree with each other, leading to the use of an averaged readability (composite) score for comparison. The composite scores across all online PEMs were not normally distributed and had a median at the 11th grade. Governmental PEMs were the easiest to read amongst source categorizations and PEMs about menstruation were the most difficult to read. However, the differences in the readability scores among the sources and the topics were small.

CONCLUSIONS

This study found that online OB/GYN PEMs did not meet the AMA and NIH readability recommendations and would be difficult to read and comprehend for patients with low health literacy. Both findings connected well to the literature. This study highlights the need to improve the readability of OB/GYN PEMs to help patients make informed decisions. Research has been done to create more sophisticated readability measures for medical and health documents. Once validated, these tools need to be used by web-based content creators of health education materials.

Low-intensity pulsed ultrasound in obstetrics and gynecology: advances in clinical application and research progress

In the past decade, research on ultrasound therapy in obstetrics and gynecology has rapidly developed. Currently, high-intensity ultrasound has been widely used in clinical practice, while low-intensity ultrasound has gradually emerged as a new trend of transitioning from pre-clinical research to clinical applications. Low-intensity pulsed ultrasound (LIPUS), characterized by a non-invasive low-intensity pulse wave stimulation method, employs its non-thermal effects to achieve safe, economical, and convenient therapeutic outcomes. LIPUS converts into biochemical signals within cells through pathways such as cavitation, acoustic flow, and mechanical stimulation, regulating molecular biological mechanisms and exerting various biological effects. The molecular biology mechanisms underlying the application of LIPUS in obstetrics and gynecology mainly include signaling pathways, key gene expression, angiogenesis, inflammation inhibition, and stem cell differentiation. LIPUS plays a positive role in promoting soft tissue regeneration, bone regeneration, nerve regulation, and changes in cell membrane permeability. LIPUS can improve the treatment benefit of premature ovarian failure, pelvic floor dysfunction, nerve damage caused by intrauterine growth restriction, ovariectomized osteoporosis, and incomplete uterine involution through the above biological effects, and it also has application value in the adjuvant treatment of malignant tumors such as ovarian cancer and cervical cancer. This study outlines the biological mechanisms and applications of LIPUS in treating various obstetric and gynecologic diseases, aiming to promote its precise application and provide a theoretical basis for its use in the field.

Value of Hospice and Palliative Medicine Fellowship After Surgical Training: Bridging the Gap for Improved Patient Care

Objective: Surgeons comprise 2% of HPM-trained physicians. Little is known about the perceived value of HPM training to the surgeon or medical community. We aim to demonstrate the value of HPM fellowship training to surgeons and surgical practice from the point of view of HPM fellowship trained surgeons. Design: A qualitative analysis was performed using semi-structured zoom interviews that elicited the lived experiences of HPM trained surgeons. Data was analyzed using descriptive statistics and thematic analysis. Setting: Researchers were from the University of Kansas School of Medicine and the University of Alabama at Birmingham. Participants were trained and worked across the United States in a variety of settings. Participants: Eligibility included training in general surgery, obstetrics and gynecology, or affiliated subspecialties and completion of a 1-year HPM fellowship. Results: 17 interviews were performed. Several themes emerged regarding the transformative value of HPM training to their medical and surgical practice: (1) Learning to apply shared decision making and goal-concordant care to surgical decision making, and (2) Decreasing personal bias in medical decision making, and (3) Enabling wellness in surgeons. Two themes emerged regarding the perceived value to both the surgical community and the HPM community: (1) Value of the HPM Fellowship Trained Surgeon to the Surgical Community, and (2) Value of the HPM Fellowship Trained Surgeon to the HPM Community. All study participants valued their HPM training and felt highly valued by the healthcare team. Conclusion: HPM trained surgeons are highly valued on the healthcare team and improve patient-centered surgical care.

Role of telemedicine in obstetrics and gynecology: an experience at tertiary care center

BACKGROUND

The telemedicine/telehealth is well established and rapidly evolving innovation in modern practice of medicine. It is used in nearly every aspect of obstetrics and gynecology. Telehealth intervention may reduce the need for in-person visits amongst high-risk obstetric patients. It is an effective innovation for chronic gynecological conditions.

RESEARCH DESIGN AND METHODS

This was a prospective, observational study where the online platform 'e-Sanjeevani' was used. It was a health care worker to doctor (specialist) consultation regarding the patient. After an interaction, provisional diagnosis and management plan was made, and an electronic prescription for the same was generated and printed at the patient's end.

RESULTS

A total of 3219 patients were attended in 10 months. The majority of the cases had a gynecological problem (71.5%), with menstrual irregularity being the commonest. Among pregnant patients, consultations for early pregnancy complications were made in 29% of the cases. 5.8% were referred because of some surgical intervention.

CONCLUSION

Non-emergency patients who can be managed medically can be prevented from unnecessary visits to the hospital and managed through teleconsultation, which decreases the burden of patient load at the tertiary center.

Consent and refusal of procedures during labour and birth: a survey among 11 418 women in the Netherlands

BACKGROUND

Informed consent for medical interventions is ethically and legally required; an important aspect of quality and safety in healthcare; and essential to person-centred care. During labour and birth, respecting consent requirements, including respecting refusal, can contribute to a higher sense of choice and control for labouring women. This study examines (1) to what extent and for which procedures during labour and birth women report that consent requirements were not met and/or inadequate information was provided, (2) how frequently women consider consent requirements not being met upsetting and (3) which personal characteristics are associated with the latter.

METHODS

A national cross-sectional survey was conducted in the Netherlands among women who gave birth up to 5 years previously. Respondents were recruited through social media with the help of influencers and organisations. The survey focused on 10 common procedures during labour and birth, investigating for each procedure if respondents were offered the procedure, if they consented or refused, if the information provision was sufficient and if they underwent unconsented procedures, whether they found this upsetting.

RESULTS

13 359 women started the survey and 11 418 met the inclusion and exclusion criteria. Consent not asked was most often reported by respondents who underwent postpartum oxytocin (47.5%) and episiotomy (41.7%). Refusal was most often over-ruled when performing augmentation of labour (2.2%) and episiotomy (1.9%). Information provision was reported inadequate more often when consent requirements were not met compared with when they were met. Multiparous women had decreased odds of reporting unmet consent requirements compared with primiparous (adjusted ORs 0.54-0.85). There was considerable variation across procedures in how frequently not meeting consent requirements was considered upsetting.

CONCLUSIONS

Consent for performing a procedure is frequently absent in Dutch maternity care. In some instances, procedures were performed in spite of the woman's refusal. More awareness is needed on meeting necessary consent requirements in order to achieve person-centred and high-quality care during labour and birth.

Medical Professional Liability in Obstetrics and Gynecology: A Pilot Study of Criminal Proceedings in the Public Prosecutor's Office at the Court of Rome

Criminal trials and claims against physicians for malpractice-related damages have increased dramatically in recent years, and, with Obstetrics and Gynecology being one of the medical specialties that is at the highest risk, we carried out a retrospective analysis aimed at examining all Obstetrics- and Gynecology-related medical professional liability prosecutions within the General Register of Criminal Records of the Rome Public Prosecutor's Office between the years 2000 and 2014. The number of prosecutions increased steadily in the years 2000-2005, with varying trends in the following years. A total of 727 healthcare professionals were involved in criminal charges, and most prosecuted crimes were related to Articles 590 and 589 of the Italian Penal Code, followed by violations of Article 17 of Law 194/78. In most cases, filing was requested and granted without opposition. In 95 cases, an expert witness was appointed by the Court, and in 68 cases, the technical consultants of the State Prosecutor found culpable conduct. Public hospitals, private nursing homes and outpatient clinics, or private practices were mostly involved; in 45% of the cases, the physicians were hospital employees. In this setting, Italy is prepared to introduce new measures and regulations to address the issues posed by defensive medicine and charges of professional liability for healthcare providers.

The end of Roe v. Wade: implications for Women's mental health and care

The Supreme Court decision in Dobbs v. Jackson in June 2022 reversed precedent which had previously protected abortion prior to fetal viability as a universal right within the United States. This decision almost immediately led to abortion restrictions across 25 states. The resulting lack of access to abortion care for millions of pregnant people will have profound physical and mental health consequences, the full effects of which will not be realized for years to come. Approximately 1 in 5 women access abortions in the U.S. each year. These women are diverse and represent all American groups. The Supreme court decision, however, will affect populations that have and continue to be marginalized the most. Forcing pregnant individuals to carry unwanted pregnancies worsens health outcomes and mortality risk for both the perinatal individual and the offspring. The US has one of the highest maternal mortality rates and this rate is projected to increase with abortion bans. Abortion policies also interfere with appropriate medical care of pregnant people leading to less safe pregnancies for all. Beyond the physical morbidity, the psychological sequelae of carrying a forced pregnancy to term will lead to an even greater burden of maternal mental illness, exacerbating the already existing maternal mental health crisis. This perspective piece reviews the current evidence of abortion denial on women's mental health and care. Based on the current evidence, we discuss the clinical, educational, societal, research, and policy implications of the Dobbs v. Jackson Supreme Court decision.

[The application of statistical programs and methods of data mathematical processing in obstetrics and gynecology]

In recent decades, evidence-based medicine acquired special importance in medicine. Therefore, proper presentation of data obtained in scientific research is extremely important. The statistical data processing, being an integral part of this process, often causes difficulties for researchers and its incorrect application results in distortion of results obtained. The purpose of the study is to comparatively analyze programs and methods of statistical data processing applied in dissertations on obstetrics and gynecology in 2011-2021, to examine trends in choosing them depending on specificity of research issue and to identify shortcomings erred by authors in choosing or describing data processing methods. The sampling for analysis included 258 abstracts of candidate's dissertations in the specialty "obstetrics and gynecology", defended in 2011-2021. The analysis covered the programs and methods of mathematical data processing. Over the past decade, significant complication of statistical processing of results of clinical trials in obstetrics and gynecology occurred in part of methods applied. The application of binary logistic regression and discriminant analysis increased most significantly over the past decade. Such sophisticated methods of statistical data processing as factor analysis, decision trees, ordinal logistic regression and neural networks began to be used too. The trend of gradual replacement of parametric methods (Student's t-test, one-way analysis of variance) by such corresponding non-parametric methods as Mann-Whitney test, Kruskal-Wallis test. The Microsoft Excel and Statistica were used most often for data processing. In recent years, the software SPSS Statistics is actively applied. However, problems in describing statistical methods used in dissertations continue to be present. In significant part of dissertations information about statistical program applied, methods of assessing of quantitative data distribution and criteria of significance of obtained results is absent. The proper application of statistical programs, methods of information processing, adequate interpretation of results as well as provision of complete information about methodological support are the key points to carry out modern research resulting in trusted attitude to scientific work and its results.

Anatomy in the daily practice of the gynecologist, essential or just window dressing?

Traditionally, anatomy was one of the basic pillars of medical training. However, due to the expansion of medical science and medical knowledge in general, anatomy teaching has steadily declined and the way anatomy is taught has changed. These changes go hand in hand with growing literature about a perceived and proven lack of anatomical knowledge. While anatomy is important for all doctors, these developments seem to be more worrying for surgical residents. At the same time, little is known about how clinicians use anatomy in daily practice. The primary aim of this study was to increase understanding of the role of anatomy in the daily practice of gynecologists. An explorative qualitative study was performed to answer the question "What is the tangible utility of solid anatomical knowledge in the daily practice of the gynecologist"? Semi-structured interviews with gynecologists and obstetrics and gynecology (ObGyn) residents from Belgium and the Netherlands were held and the responses were analyzed using a phenomenographic inductive coding approach. Anatomical knowledge was important and used for technical skills and non-technical achievements in the daily practice of gynecologists, and three themes were distinguished. Specifically, anatomical knowledge was important and used (1) for daily activities, (2) for the feeling of self-efficacy, and (3) to gain a respected name as a doctor. These findings are discussed in light of (perceived) insufficient anatomical knowledge, and recommendations are made for the postgraduate education of ObGyn doctors.

Uterine Artery Embolization in a Patient With Large Uterine Fibroids

A woman in her 20s with no past medical history presented to the emergency department with a 4-day history of abdominal pain. Imaging revealed several large uterine fibroids that compressed various intra-abdominal structures. Options of observation, medical management, surgical management with abdominal myomectomy, and uterine artery embolization (UAE) were discussed. The patient was counseled about the associated risks of UAE and myomectomy. Since both procedures have a risk of infertility, the patient elected to proceed with uterine artery embolization due to the less invasive nature of the procedure. She was discharged after one day in the hospital following the procedure and readmitted three days later for suspected endometritis. The patient was treated with antibiotics for five days and discharged home. Eleven months post-procedure, the patient became pregnant. The patient had achieved a full-term delivery at 39 weeks and two days via a cesarean section secondary to a breech presentation.

ChatGPT Outscored Human Candidates in a Virtual Objective Structured Clinical Examination (OSCE) in Obstetrics and Gynecology

BACKGROUND

Natural language processing is a form of artificial intelligence that allows human users to interface with a machine without using complex code. The ability of natural language processing systems such as ChatGPT to successfully engage with healthcare systems requiring fluid reasoning, specialist data interpretation, and empathetic communication in an unfamiliar and evolving environment is poorly studied. We tested whether the ChatGPT interface could engage with and complete a mock Objective Structured Clinical Examination simulating assessment for Membership of the Royal College of Obstetricians and Gynaecologists.

OBJECTIVES

We hypothesized that, without additional training, ChatGPT would achieve a score at least equivalent to that achieved by human candidates who sat for a virtual Objective Structured Clinical Examinations in Singapore.

STUDY DESIGN

The study was conducted in two phases. In the first, a total of seven structured discussion questions were selected from two historical cohorts (Cohorts A and B) of objective structured clinical examination questions. ChatGPT was examined using these questions and responses recorded in a script. Two human candidates (acting as anonymizers) were then examined on the same questions using videoconferencing, and their responses were transcribed verbatim into written scripts. The three sets of response scripts were then mixed, and each set allocated to one of three human actors. In the second stage, actors were used to present these scripts to examiners in response to the same examination questions. These responses were blind-scored by fourteen qualified examiners. ChatGPT scores were then unblinded and compared to historical human candidate performances.

RESULTS

The average ChatGPT score given to ChatGPT by 14 examiners was 77.2 %. The average historical human score (n=26 candidates) was 73.7 %. ChatGPT demonstrated sizable performance improvements over the average human candidate in several subject domains. The median time taken for ChatGPT to complete each station was 2.54 minutes, well before the ten-minutes allowed.

CONCLUSIONS

ChatGPT generated factually accsturate and contextually relevant structured discussion answers to complex and evolving clinical questions based on unfamiliar settings within a very short period. ChatGPT outperformed human candidates in several knowledge areas. Not all examiners were able to discern between human and ChatGPT responses. Our data highlight the emergent ability of natural language processing models to demonstrate fluid reasoning in unfamiliar environments and successfully compete with human candidates that have undergone extensive specialist training.

Virtual reality learning: A randomized controlled trial assessing medical student knowledge of fetal development

OBJECTIVE

To investigate whether a virtual reality learning environment (VRLE) enhanced student understanding and knowledge compared with a traditional tutorial.

METHOD

A randomized controlled trial involving medical students from University College Dublin, Ireland. Participants were assigned to an intervention (VRLE involving a 15-min learning experience on the stages of fetal development) or control (PowerPoint tutorial on the same topic) group. Multiple choice questionnaires (MCQs) assessed knowledge at three time points: preintervention, immediately postintervention, and 1 week postintervention. Primary outcomes were differences in MCQ knowledge scores postintervention between groups. Secondary outcomes included attitudes on the learning experience assessed using the Student Satisfaction and Self-Confidence in Learning Scale (SCLS) and the Virtual Reality Design Scale (VRDS).

RESULTS

No statistically significant between-group differences were found in the primary outcome assessing postintervention knowledge scores. Within-group differences in knowledge scores were significant among the three time points for both the intervention (P < 0.01 [95% confidence interval, 5.33-6.19]) and control (P = 0.02 [95% confidence interval, 5.74-6.49]) groups. Mean levels of satisfaction and self-confidence in learning were higher in the intervention group compared with the control group: 54.2 (standard deviation, 7.5) and 50.5 (standard deviation, 7.2), respectively (P = 0.21).

CONCLUSION

VRLEs are a learning tool that can support knowledge development.

Gender Inclusive Research Instructions in Author Submission Guidelines: Results of a Cross-Sectional Study of Obstetrics and Gynecology Journals

BACKGROUND

People with marginalized gender identities, including people with transgender and gender-expansive identities, have been historically excluded from research. Professional societies recommend the use of inclusive language in research, but it is uncertain how many obstetrics and gynecology journals mandate the use of gender inclusive research practices in their author guidelines.

OBJECTIVE

To evaluate the proportion of "inclusive" journals with specific instructions about gender inclusive research practices in their author submission guidelines, and to compare these journals to "non-inclusive" journals based on publisher, country of origin, and several metrics of research influence. Another objective was to qualitatively evaluate the components of inclusive research in author submission guidelines.

METHODS

We performed a cross-sectional study of all obstetrics and gynecology journals in the Journal Citation Reports, a scientometric resource, in April 2022. One journal was indexed twice (due to a name change), and only the journal with a 2020 Journal Impact Factor was included. Author submission guidelines were reviewed by 2 independent reviewers to identify inclusive versus non-inclusive journals based on whether journals had gender inclusive research instructions. Journal characteristics, including publisher, country of origin, impact metrics (e.g., Journal Impact Factor), normalized metrics (e.g., Journal Citation Indicator), and source metrics (e.g., number of citable items), were evaluated for all journals. Median (interquartile range [IQR]) and median difference between inclusive versus non-inclusive journals with bootstrapped 95% confidence interval were calculated for journals with 2020 Journal Impact Factors. We also thematically compared inclusive research instructions to identify trends.

RESULTS

Author submission guidelines were reviewed for all 121 active obstetrics and gynecology journals indexed in Journal Citation Reports. Overall, 41 (33.9%) journals were inclusive, and 34 (41.0%) journals with 2020 Journal Impact Factor were inclusive. Most inclusive journals were English language publications and originated in the United States and Europe. In an analysis of journals with a 2020 Journal Impact Factor, inclusive journals had higher median Journal Impact Factor (3.4 [IQR 2.2, 4.3] versus 2.5, [IQR 1.9, 3.0] median difference 0.9, 95% confidence interval (CI) 0.2, 1.7) and median 5-year Journal Impact Factor (3.6, [IQR 2.8, 4.3] versus 2.6 [IQR 2.1, 3.2; median difference 0.9, 95% CI 0.3, 1.6) compared to non-inclusive journals. Inclusive journals had higher normalized metrics, including median 2020 Journal Citation Indicator (1.1, IQR 0.7, 1.3 versus 0.8, IQR 0.6, 1.0; median difference 0.3, 95% CI 0.1, 0.5) and median normalized Eigenfactor (1.4, IQR 0.7, 2.2 versus 0.7, IQR 0.4, 1.5; median difference 0.8, 95% CI 0.2, 1.5). Inclusive journals also had higher source metrics, including more citable items, total items, and Open Access Gold subscriptions. The qualitative analysis of gender inclusive research instructions revealed that most inclusive journals recommend that researchers use gender-neutral language and provide specific examples of inclusive language.

CONCLUSIONS

Fewer than half of obstetrics and gynecology journals with 2020 Journal Impact Factor have gender inclusive research practices in their author submission guidelines. The study underscores the urgent need for a majority of obstetrics and gynecology journals to update their author submission guidelines to include specific instructions about gender inclusive research practices.

Patient-reported outcome and experience measures for quality improvement in pregnancy and childbirth care: a retrospective cohort study

BACKGROUND

Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) can highlight issues that remain unnoticed when using standard clinical quality indicators. However, estimations of the potential power of measuring PROMs and PREMs to identify unrecognised areas suitable for quality improvement are often limited by a lack of reliable real-world data. Here, we report on how the indicator set for PROMs and PREMs that was recently developed by the International Consortium for Health Outcome Measures can change perspectives on quality assessment in women receiving care for pregnancy and childbirth.

METHODS

PROMs and PREMs were captured 6 months after childbirth via an online survey in a single academic maternity unit in the Netherlands between 2018 and 2019. Indicators of abnormality were scored using predefined cut-off values established by a national consensus group. We used regression analysis to identify associations between PROMs, PREMs and healthcare use, and further stratified data to explore the distribution of indicators among relevant patient subgroups.

RESULTS

Of 2775 questionnaires, 645 were completed and linked to medical health records. Despite only 5% of women reporting overall dissatisfaction with care, suboptimal scores were often found; in birth experience for 32% of the population, and 42% who experienced painful sexual intercourse. Subgroup analysis further revealed associations with relevant indicators of quality of care; inadequate pain relief among women with preterm birth (OR 8.8), pain with sexual intercourse among women undergoing vaginal assisted delivery (OR 2.2) and women living in a deprived area had problematic birth experiences (coefficient -3.2).

CONCLUSION

Use of PROMs and PREMs in pregnancy and childbirth care provides new insights on quality of care, resulting in potentially actionable targets for improvement not normally identified with standard clinical quality indicators. Implementation strategies and follow-up are needed to act on these findings.

Understanding factors that influence whether a woman will seek care for reproductive health: A national survey

A number of studies have characterized the importance of regular OB/GYN visits for women who are above the age of 18. As more emphasis is placed on reproductive healthcare, there has been an overall decrease in the rates of adverse sexual and reproductive health outcomes. In this study, a population of 200 women were surveyed to find factors that influence whether they had sought care from an OB/GYN in the past year. These results can be further extrapolated to whether women will seek OB/GYN healthcare in the future. A survey research platform was used to collect demographic data in addition to the survey responses. Thirteen survey questions were designed, some of which were adapted from the NIH Healthcare Access and Utilization Survey. This study found that women of minority races (African American and Hispanic) were more likely to report that they didn't feel like they were asked for their opinions about their healthcare. Additionally, women who were younger, who didn't feel like they were asked for their opinions, and who were of minority races were more likely to have not seen an OB/GYN in the past year. These findings can be used to focus on fixing the factors that deter women from seeking regular OB/GYN care. Efforts must be made to ensure that patients feel supported and understood, for this is the only way that we can make progress towards a healthier society.

Living uterus donors' perceptions of decision-making and informed consent: a qualitative study of the Dallas Uterus Transplant Study participants

Uterus transplantation is a growing field, but little is known about living uterus donors' perceptions of informed consent or their decision-making processes. This study used semistructured interviews to collect information regarding uterus donors' experiences with uterus donation, perceptions of the informed consent process, and information on how they decided to pursue uterus donation. Interviews were coded for thematic analysis. Three major themes emerged in this study. First, the decision-making process was based on individuals' motivations, rationale, and considerations of alternative contributions to help other women with infertility. Second, participants described how they felt about the process of informed consent, their decision-making processes, and how their experiences compared with their expectations. Third, participants discussed how uterus donation was a valuable experience. This study found that living uterus donors are motivated to give another woman the opportunity to experience pregnancy and childbirth. They were satisfied with the informed consent process, their experiences were in line with their expectations, and the value of uterus donation was associated with the act of donation itself. Our findings suggest that living donor uterus programs should develop robust informed consent processes that provide detailed information about uterus donation and encourage shared decision-making with potential uterus donors.

A laparoscopic approach to address massive splenomegaly, symptomatic cholelithiasis, and a planned postoperative pregnancy: A case report

We report long-term follow-up of a patient who underwent a tailored laparoscopic procedure for symptomatic cholelithiasis, massive splenomegaly, and a planned pregnancy. There were no complications, and the patient remained symptom-free at the 5-year follow-up. We supplemented our case report with national surgical data demonstrating the safety of laparoscopic splenectomy.

Effect of Absenteeism on Student's Performance in Different Components of Examinations - A Comparison of Online Verses Offline Teaching

Background

The In online learning, more responsibility is shifted towards students in learning according to their needs. However there is a need to assess which component of teaching can be shifted online for future hybrid teachings.

Objective

This study aims to compare the students' performance in difference components of the exams and compare them in online vs offline.

Methods

It was a quantitative study comparing onsite and online groups academic performance in individual components of assessment for a duration of 6 months. Estimates were reported per standard deviation (SD) increase or decrease. Taking absenteeism rate as a predictor, models with group and gender on their own was fitted in univariable models, before including all three predictors (absenteeism rate, group and gender) in the final model.

Results

Students who studied online, had a 0.49SD higher grade than their counterparts who attended physically (p < 0.001), each SD increase in the absenteeism rate was associated with a 0.26SD lower overall score, and this was significant, p < 0.001. While comparing both groups in MCQ part students who studied online, had a 0.6SD higher grade than their counterparts (p < 0.001), also in continuous assessment students who studied online, had a 0.49 SD higher grade than their counterparts who attended physically (p < 0.001).

Conclusion

Positive effect of the online teaching was clear in the (MCQs) and the final result, while no significant gender variation detected in this study.

Gender Differences of Endowed Professorship in Obstetrics and Gynecology Departments at Top Academic Institutions

Background: Gender equity is a critical issue in academic medicine. Whether there is equitable access to the prestige and resources of endowed professorships merits evaluation. We investigated this question in obstetrics and gynecology, a field that focuses on the health of women and in which women are much better represented than other specialties of medicine. Materials and Methods: We compiled a list of the top 25 United States departments of obstetrics and gynecology and contacted department chairs (and used department websites) to obtain lists of faculty and their positions. Scopus, department websites, and National Institutes of Health (NIH) RePORTER were used to collect h-Index, number of publications and citations, graduation year, degrees, gender, and NIH-funding. We conducted a bivariate comparison of endowed professorship attainment by gender using a chi-square test and created a multiple variable regression model. Results: Of the 680 obstetrics and gynecology faculty across 23 departments that had endowed chairs, 64 out of 400 women (16%) and 66 out of 280 men (24%) held endowed chairs (p = 0.01). The multivariable model suggested no independent gender difference in attainment of an endowed chair after adjusting for covariates. Conclusion: To our knowledge, this study is the first to examine gender as a variable in endowed chair allocation in top obstetrics and gynecology academic departments. Our findings suggest a significant gender difference in the allocation of endowed chairs. That difference is driven by gender differences in academic rank, graduation year, publications, and funding. To promote the intraprofessional equity necessary to optimally advance women's health, further research and intervention are necessary.

Use of quality improvement methodology to improve care of women with hypertensive disease in pregnancy and haemorrhage in Yemen (low-income, high-insecurity setting)

This safety improvement project used quality improvement methods in a Comprehensive Emergency Obstetric and Newborn Care facility in Yemen, managed by an international humanitarian non-governmental organisation. It is responsible for about 6500 deliveries per annum. Following a local review of maternal deaths and serious incidents in 2020-2021, care for women with severe hypertensive disease in pregnancy and postpartum haemorrhage were highlighted as potential areas for improvement. These are also the two most common reasons recorded for maternal mortality in Yemen (and in many low-income countries worldwide). We also wanted to foster an open and honest safety culture within the department that encouraged learning from error.We used an inclusive approach in designing the improvements, with change ideas collated via frontline doctors, midwives and nurses working in the maternity unit. Data were collected via manual audit, and through routinely collected data. We focused on the following measures: number of incidents reported per month, documentation quality of antihypertensive prescriptions, fluid restriction practices in women with severe pre-eclampsia, number of minutes taken to control severe hypertensive episodes, postpartum haemorrhage identification rates and tranexamic acid stock usage. We evaluated the efficacy of team simulation training through precourse and postcourse questionnaires.We found demonstrable improvement in our measures relating to treatment of women with hypertensive disorders of pregnancy, and in postpartum haemorrhage identification and treatment. Team simulation training was a difficult intervention to sustain but was received well with positive results during our test session. Incident reporting showed a temporary increase, but this effect was not sustained.We concluded that quality improvement methodology is a valuable tool even in challenged healthcare settings such as this one, in an active conflict zone. Behaviour change in team culture and safety culture is harder to sustain and demonstrate without a long-term strategy.