Association between acceptance of routine pregnancy vaccinations and COVID-19 vaccine uptake in pregnant patients.

OBJECTIVE: COVID-19 vaccination is a key approach to reduce morbidity and mortality in pregnant patients and their newborns. Anti-vaccine sentiment has recently increased with unclear impact on pregnant patients. We examined the association between acceptance of tetanus-diphtheria-acellular pertussis (Tdap) and influenza vaccines, considered to be routine pregnancy vaccines, and COVID-19 vaccine acceptance. Secondarily, we identified other predictors of COVID-19 vaccine uptake and described pregnancy outcomes in patients who were and were not vaccinated during pregnancy. METHODS: A retrospective cohort study of all patients who delivered at a single site from December 2020 - March 2022. Demographic, pregnancy, neonatal, and vaccination data were abstracted from the electronic medical record, which imports vaccine history from the California Immunization Registry. The relationship between influenza and Tdap vaccine acceptance, other baseline characteristics, and COVID-19 vaccine uptake was assessed using univariable and multivariable regression analysis. RESULTS: Of the 7857 patients who delivered during the study period, 4410 (56.1%) accepted the COVID-19 vaccine. Of those who received the COVID-19 vaccine, 3363 (97.6%) and 3049 (88.5%) received influenza and Tdap vaccines, respectively. Patients were more likely to receive the COVID-19 vaccine if they had advanced maternal age, obesity, Asian race, and private insurance. After adjustment for baseline differences, COVID vaccine acceptance was associated with receipt of Tdap (aOR 2.10, 95% CI 1.90-2.33) and influenza vaccines (aOR 2.83, 95% CI 2.55-3.14). There were no differences in preterm birth, low birthweight, and NICU admission between patients who received and did not receive the COVID-19 vaccine. CONCLUSION: Patients were more likely to accept COVID-19 vaccination if they received Tdap or influenza vaccinations. Older age, obesity, Asian race, and private insurance were independent predictors of vaccine uptake. Disparities in COVID-19 vaccination uptake bear further exploration to guide efforts in equitable and widespread vaccine distribution.

Factors Associated With Coronavirus Disease 2019 Vaccine Uptake Among Pregnant Women and Nonpregnant Women of Reproductive Age in Jamaica.

Background: Despite high rates of coronavirus disease 2019 (COVID-19)-related maternal mortality, Jamaica currently has little data on COVID-19 vaccine uptake among pregnant women. Methods: We conducted a cross-sectional, web-based survey of 192 reproductive-aged women in Jamaica from February 1 to 8, 2022. Participants were recruited from a convenience sample of patients, providers, and staff at a teaching hospital. We assessed self-reported COVID-19 vaccination status and COVID-19-related medical mistrust (operationalized as vaccine confidence, government mistrust, and race-based mistrust). We used multivariable modified Poisson regression to test the association between vaccine uptake and pregnancy. Results: Of 192 respondents, 72 (38%) were pregnant. Most (93%) were Black. Vaccine uptake was 35% in pregnant women versus 75% in nonpregnant women. Pregnant women were more likely to cite healthcare providers versus the government as trustworthy sources of COVID-19 vaccine information (65% vs 28%). Pregnancy, low vaccine confidence, and government mistrust were associated with a lower likelihood of COVID-19 vaccination (adjusted prevalence ratio [aPR] = 0.68 [95% confidence interval {CI}, .49-.95], aPR = 0.61 [95% CI, .40-.95], and aPR = 0.68 [95% CI, .52-.89], respectively). Race-based mistrust was not associated with COVID-19 vaccination in the final model. Conclusions: Pregnancy, low vaccine confidence, and government mistrust were associated with a lower likelihood of COVID-19 vaccination among reproductive-aged women in Jamaica. Future studies should evaluate the efficacy of strategies proven to improve maternal vaccination coverage, including standing "opt-out" vaccination orders and collaborative provider and patient-led educational videos tailored for pregnant individuals. Strategies that decouple vaccine messaging from government agencies also warrant evaluation.

Provider confidence in counseling preconception, pregnant, and postpartum patients regarding COVID-19 vaccination: A cross-sectional survey study.

Background and Aims: Healthcare provider counseling surrounding COVID-19 vaccine in pregnancy and lactation is essential to vaccination uptake in this population; however, provider knowledge and confidence are not well characterized. We aimed to assess knowledge and confidence in COVID-19 vaccine counseling among practitioners who provide care to pregnant persons and to describe factors associated with confidence in counseling. Methods: A web-based anonymous survey was distributed via email to a cross-sectional convenience sample of Obstetrics and Gynecology, Primary Care, and Internal Medicine faculty at three hospitals in a single healthcare network in Massachusetts, United States. Individual demographics and institution-specific variables were included in the survey along with questions assessing both attitudes toward COVID-19 illness and confidence in counseling regarding the use of the vaccine in pregnancy. Results: Almost all providers (151, 98.1%) reported that they received a COVID-19 vaccine, and most (111, 72.1%) reported that they believe the benefits of the vaccine in pregnancy outweigh the risks. Forty-one (26.6%) reported feeling very confident in counseling patients who primarily speak English about the evidence for messenger ribonucleic acid vaccination in pregnancy, and 36 (23%) reported feeling very confident in counseling patients who are not primarily English-speaking. Forty-three providers (28.1%) expressed strong confidence in their comfort talking to individuals with vaccine hesitancy based on historic and continued racism and systemic injustices. The sources that survey respondents most used to find information regarding COVID-19 vaccination in pregnancy were the Centers for Disease Control (112, 74.2%), hospital-specific resources (94, 62.3%), and the American College of Obstetricians and Gynecologists (82, 54.3%). Conclusion: Ensuring that providers feel comfortable bridging the gap between their belief that the vaccine is beneficial for pregnant patients and their comfort with holding conversations with patients regarding vaccination is paramount to ensure equitable access to vaccines for pregnant patients.

Availability Versus Accessibility: Identifying COVID-19 Testing Deserts Across Massachusetts.

Throughout the COVID-19 pandemic, communities of color have faced significantly higher rates of COVID-19 infection, as well as poor clinical outcomes. These differences are driven by long-standing structural inequities that prevent effective social distancing efforts and are further exacerbated by disparities in COVID-19 testing. Our study applied the concept of "COVID-19 testing deserts" to systematically identify gaps in testing resource allocation across Massachusetts in May 2020 and March 2021. Testing deserts were identified at the census tract level, using criteria developed by the Department of Agriculture for food deserts. Testing deserts occurred more frequently in segregated Hispanic, segregated Black, mixed minority, and integrated communities, as well as in neighborhoods with low vehicle access and in federally designated Medically Underserved Areas. Segregated communities were those in which more than 50 percent of the population self-identified as non-Hispanic White, Hispanic, non-Hispanic Black, or non-Hispanic Asian, respectively. Testing deserts were overrepresented in counties with high COVID-19 incidence rates, suggesting that testing accessibility is essential for prompt COVID-19 diagnosis and self-isolation.

First Trimester Cardiac Biomarkers among Women with Peripartum Cardiomyopathy: Are There Early Clues to This Late-Pregnancy Phenomenon?

OBJECTIVE: Whether biomarkers may enable early identification of women who develop peripartum cardiomyopathy (PPCM) prior to disease onset remains a question of interest. STUDY DESIGN: A retrospective nested case-control study was conducted to determine whether first trimester N-terminal pro-B type natriuretic peptide (NT-proBNP) or high sensitivity cardiac troponin I (hs-cTnI) differed among women who developed PPCM versus unaffected pregnancies. Cases were matched to unaffected women by age, race, parity, and gestational age of sample (control A) and then further by blood pressure and pregnancy weight gain (control B). RESULTS: First trimester NT-proBNP concentrations were numerically higher among women who subsequently developed PPCM (116 pg/mL [83-177]) as compared with women in control A (56.1 pg/mL [38.7-118.7], p = 0.3) or control B (37.6 [23.3 - 53.8], p <0.05). A higher proportion of women who subsequently developed PPCM (50%) had detectable levels of hs-cTnI as compared with control A (0%, p = 0.03) or control B (18.8%, p = 0.52). Among both cases and controls, hs-cTnI values were low and often below the limit of detection. CONCLUSION: There were differences in first trimester NT-proBNP and hs-cTnI concentrations between women who subsequently developed PPCM and those who did not, raising the possibility the early pregnancy subclinical myocardial dysfunction may be associated with this late-pregnancy disease. KEY POINTS: · First trimester NT-proBNP is numerically higher among women who subsequently develop PPCM.. · First trimester hs-cTnI was nominally higher among women who developed PPCM versus those who did not.. · A significant proportion of normal pregnant women have undetectable hs-cTnI..

Experiences Navigating the Pregnancy Care Continuum During the COVID-19 Pandemic.

INTRODUCTION: The COVID-19 pandemic led to unprecedented changes in care delivery across the pregnancy care continuum. Our primary objective with this research was to characterize the range of ways that the early months of the COVID-19 pandemic affected pregnancy, childbirth, and postpartum care experiences. METHODS: Pregnant and recently pregnant patients (n = 20) from obstetrics and gynecology clinical sites associated with Massachusetts General Hospital were interviewed about their experiences with prenatal care, childbirth, and postpartum care during the first wave of the COVID-19 pandemic. Interview transcripts were analyzed for emergent themes. RESULTS: This sample included 20 pregnant and postpartum people, including 11 individuals who tested positive for COVID-19 during pregnancy or postpartum and nine with suspected infection. The ways in which COVID-19 or suspected COVID-19 affected experiences of prenatal care, childbirth, and postpartum care were complex and varied. Three themes were identified across narratives of pregnancy, birth, and postpartum care: patient perceptions of diminished access to care, stigma due to COVID-19 infection, and limited capacity of providers to honor patient preferences. CONCLUSIONS: A better understanding of pregnant and recently pregnant people's experiences during the early months of the COVID-19 pandemic can inform infection control policies and clinical care delivery practices that are more congruent with the needs and values of pregnant, birthing, and postpartum people as institutions craft responses to future pandemics. Approaches that maximize meaningful access across the pregnancy care continuum, center patients' priorities within adapted care models, and honor patient preferences as much as possible are important aspects of an appropriate response to future waves of COVID-19 and other pandemics.

Medical Students' Intention to Change After Receiving Formative Feedback: Employing Social Cognitive Theories of Behavior.

Introduction: We applied Azjen's theory of planned behavior (TPB) and Triandis' theory of interpersonal behavior (TIB) to understand medical students' intention to change behavior based on feedback received during an obstetrics and gynecology clerkship. Both models presume that behavioral intention is strongly related to actual behavior. Materials and Methods: We collected free-text responses from students during a year-long Feedback Focused initiative on the obstetrics and gynecology clerkship at Harvard Medical School. Students reported feedback daily and what they would change based on that feedback. We applied TPB and TIB to identify students' motivation to change. We analyzed data using directed content analysis. Results: We reviewed 1,443 feedback entries from 122 students between July 2, 2018, and May 31, 2019. Self-efficacy was the most commonly represented component, related to a student expressing their own role, ability, or skill integrating the feedback (85%). Some entries (11%) focused on students' attitudes or beliefs about the outcome of the implemented feedback, usually patient focused but sometimes about the learner's outcome. Intentions motivated by social norms and expectations focused on the perceived or stated expectations of others, usually a superior or a team (11%). A small number of entries (1.7%) indicated that students had an emotional response to challenging or meaningful feedback. Conclusions: While self-efficacy is an important change motivator, faculty development geared toward improving the provision of meaningful feedback that bridges a desired behavior change to an outcome of interest, framed through the attitudes and beliefs or social norms lens, may improve trainee performance.

Perceptions and Attitudes toward COVID-19 Vaccination among Pregnant and Postpartum Individuals.

OBJECTIVE: This study aimed to characterize attitudes toward novel coronavirus disease 2019 (COVID-19) vaccination and to evaluate factors associated with vaccine uptake among pregnant individuals. STUDY DESIGN: An anonymous survey was distributed to a convenience sample of pregnant individuals receiving prenatal care at two large urban academic hospitals in a single health care network in Massachusetts. Individual demographic variables were included in the survey along with questions assessing attitudes toward COVID-19 and vaccination in pregnancy. Data were analyzed using parametric or nonparametric tests when appropriate, and associated odds ratios (OR) were calculated via univariable logistic regression. RESULTS: There were 684 surveys distributed, and 477 pregnant and postpartum individuals completed the survey, for a response rate of 69.7%. Overall, 233 (49.3%) had received or were scheduled to receive a COVID-19 vaccine. Age, White race, non-Hispanic or Latinx ethnicity, working from home, and typical receipt of the influenza vaccine were associated with COVID-19 vaccination. Further, 276 respondents (58.4%) reported that their provider recommended the COVID-19 vaccine in pregnancy; these participants were more likely to have received a vaccine (OR = 5.82, 95% confidence interval [CI]: 3.68-9.26, p < 0.005). Vaccinated individuals were less likely to be worried about the effects of the vaccine on themselves (OR = 0.18, 95% CI: 0.12-0.27, p < 0.005) or their developing babies (OR = 0.17, 95% CI: 0.11-0.26, p < 0.005). Unvaccinated individuals were less likely to report that it is easy to schedule a COVID-19 vaccine (OR = 0.56, 95% CI: 0.34-0.93, p = 0.02), to travel to receive a vaccine (OR = 0.19, 95% CI: 0.10-0.36, p < 0.005), and to miss work to receive a vaccine (OR = 0.30, 95% CI: 0.18-0.48, p < 0.005). CONCLUSION: Strategies are needed to improve patient education regarding vaccine side effects and safety in pregnancy. Policy changes should focus on making it feasible for patients to schedule a vaccine and miss work without loss of pay to get vaccinated. KEY POINTS: · There were racial and ethnic disparities in COVID-19 vaccination.. · Unvaccinated respondents were more likely to be concerned about vaccine effects for themselves or their growing babies.. · Unvaccinated respondents cited work and scheduling-related barriers to vaccination, indicating areas for advocacy..

The Effects of COVID-19 Hospital Practices on Breastfeeding Initiation and Duration Postdischarge.

Background: Early in the COVID-19 pandemic, many birth hospitals separated SARS-CoV-2-positive mothers from their newborn infants and advised against breastfeeding to decrease postnatal SARS-CoV-2 transmission. Information on how these practices impacted breastfeeding postdischarge is limited. Objectives: In a statewide sample of SARS-CoV-2-positive mothers, we aimed to determine the extent to which (1) mother-infant separation and (2) a lack of breastfeeding initiation in-hospital were associated with breast milk feeding postdischarge. Design/Methods: From 11 birthing hospitals in Massachusetts, we identified 187 women who tested positive for SARS-CoV-2 from 14 days before to 72 hours after delivery (March 1-July 31, 2020) and their newborn infants. We abstracted chart data from the delivery hospitalization on main exposure variables (mother-infant separation, in-hospital breast milk feeding [expressed milk feeding and/or direct breastfeeding]) and from outpatient visits until 30 days postdischarge. We evaluated associations of in-hospital practices with outcomes up to 30 days postdischarge, adjusting for confounders using multivariable logistic and linear regression. Results: Mother-infant separation in-hospital was associated with a shorter duration of any breast milk feeding (regression coefficient estimate -5.29 days, 95% confidence intervals [CI] [-8.89 to -1.69]). Direct breastfeeding in-hospital was associated with higher odds of any breast milk feeding (adjusted odds ratios [AOR] 5.68, 95% CI [1.65-23.63]) and direct breastfeeding (AOR 8.19, 95% CI [2.99-24.91]) postdischarge; results were similar for any breast milk feeding in-hospital. Conclusions: Perinatal hospital care practices implemented early in the COVID-19 pandemic, specifically mother-infant separation and prevention of breast milk feeding initiation, were associated with adverse effects on breast milk feeding outcomes assessed up to 1 month postdischarge.

Maternal immune response and placental antibody transfer after COVID-19 vaccination across trimester and platforms.

The availability of three COVID-19 vaccines in the United States provides an unprecedented opportunity to examine how vaccine platforms and timing of vaccination in pregnancy impact maternal and neonatal immunity. Here, we characterize the antibody profile after Ad26.COV2.S, mRNA-1273 or BNT162b2 vaccination in 158 pregnant individuals and evaluate transplacental antibody transfer by profiling maternal and umbilical cord blood in 175 maternal-neonatal dyads. These analyses reveal lower vaccine-induced functions and Fc receptor-binding after Ad26.COV2.S compared to mRNA vaccination and subtle advantages in titer and function with mRNA-1273 versus BN162b2. mRNA vaccines have higher titers and functions against SARS-CoV-2 variants of concern. First and third trimester vaccination results in enhanced maternal antibody-dependent NK-cell activation, cellular and neutrophil phagocytosis, and complement deposition relative to second trimester. Higher transplacental transfer ratios following first and second trimester vaccination may reflect placental compensation for waning maternal titers. These results provide novel insight into the impact of platform and trimester of vaccination on maternal humoral immune response and transplacental antibody transfer.

Emotional Experiences of Pregnant and Postpartum People with Confirmed or Suspected COVID-19 Infection During the Initial Surge of the Pandemic.

Objectives: The COVID-19 pandemic may have a unique emotional impact on pregnant people. This qualitative study aimed to characterize the emotional effects of the COVID-19 pandemic on pregnant and recently pregnant patients who had either suspected or confirmed COVID-19 infection during the initial 6 months of the pandemic. Methods: Pregnant and recently pregnant participants (n = 20) from Massachusetts General Hospital Obstetrics and Gynecology clinical sites with suspected or confirmed COVID-19 infection were interviewed about their experiences during the COVID-19 pandemic. Interviews were transcribed and coded using NVivo 12 software. Using data display matrices, thematic analysis was performed to identify emergent, crosscutting themes. Results: Twenty pregnant and postpartum patients participated of whom 12 had confirmed COVID-19 infection and 8 had suspected infection. The most frequently described emotions were anxiety (90%), uncertainty (80%), fear (70%), relief (65%), and sadness (60%). The following three crosscutting themes were identified: risk, protection, and change. The ways in which participants articulated their emotional reactions to the themes of risk, protection, and change were complex and varied. Conclusions: There was a broad range of negative and positive emotional experiences of pregnancy, birth, and the postpartum period during the first 4 months of the COVID-19 pandemic. A better understanding of pregnant people's emotional experiences may lead to changes in clinical practice and institutional policies that are more supportive of their needs and congruent with their values.

Prolonged Second Stage of Labor and Anal Sphincter Injury in a Contemporary Cohort of Term Nulliparas.

OBJECTIVE: This study aimed to assess whether a prolonged second stage of labor is an independent predictor of obstetric anal sphincter injury (OASI) in a contemporary cohort of nulliparous and term parturients, and to evaluate whether predelivery factors can accurately predict OASI. STUDY DESIGN: This was a nested case-control study within a cohort of consecutive nulliparous term parturients with a singleton gestation who underwent a vaginal delivery at a single institution between January 2014 and January 2015. Cases were defined as women with a third- or fourth-degree laceration at the time of delivery, and controls were women without a third- or fourth-degree laceration. A prolonged second stage was defined as a second stage of ≥3 hours. Univariable and multivariable regression analyses were performed to examine the relationship between prolonged second stage of labor and third- or fourth-degree lacerations. Receiver operator curves were developed to assess the predictive capacity of predelivery information for third- and fourth-degree lacerations. RESULTS: Of 1,197 births, 63 women had third- or fourth-degree lacerations (5.3%). With each additional hour of the second stage, the rate of OASI increased, with 2.9% of women with a second stage of <1 hour with OASI, 3.5% between 1 and 2 hours, 5.7% between 2 and 3 hours, 7.8% between 3 and 4 hours, 16.1% between 4 and 5 hours, and 28.6% among women with a second stage length >5 hours (p < 0.001). In multivariable regression analysis, operative vaginal delivery (adjusted odds ratio [aOR] = 5.92, 95% confidence interval [CI]: 3.17-11.07) and a prolonged second stage (aOR = 1.92, 95% CI: 1.06-3.51) were independent predictors of third- and fourth-degree lacerations. A predictive model was developed from these results (area under the curve [AUC] = 0.75, 95% CI: 0.68-0.81). CONCLUSION: Prolonged second stage of labor is a predictor of OASI, after adjustment for operative vaginal delivery. A model using predelivery risk factors has a reasonable prediction of OASI. KEY POINTS: · Prolonged second stage labor is associated with obstetric anal sphincter injury in term nulliparas.. · Predelivery risk factors reasonably predict obstetric anal sphincter injury in term nulliparas.. · Improved models are needed for clinical risk-stratification..

Pregnant Individuals' Views on Fetal Tissue Research in the United States.

OBJECTIVE: Fetal tissue research has driven significant medical advances but remains publicly contentious in the United States. The views of pregnant individuals in the United States regarding the donation of fetal tissue offer an important and previously unexplored perspective on this issue. METHODS: We conducted a secondary analysis of data from two separate, broader qualitative studies. Pregnant and recently pregnant individuals (N=79) from clinical sites at the University of North Carolina at Chapel Hill, Johns Hopkins University, and Massachusetts General Hospital were interviewed individually using a semi-structured guide addressing a range of issues related to infectious disease research and pregnancy, including the acceptability of fetal tissue research. Interviews were transcribed, coded, and analyzed for emergent themes. RESULTS: Among this sample of predominantly Black (61%), reproductive-aged pregnant and recently pregnant participants, the majority (72%) generally supported fetal tissue research. The following three themes were identified: choice, respect, and meaning. Respondents discussed the deeply personal nature of decisions surrounding fetal tissue research, emphasizing the importance of informed consent and respect for the person's emotional state when approaching for consent. The ways in which participants regarded how to respectfully handle fetal tissue also shaped views about the acceptability of donation, both for and against. For many participants, fetal tissue donation to research represented one way of ascribing meaning to pregnancy termination or loss. CONCLUSION: Among this diverse sample of pregnant and recently pregnant individuals, most were supportive of fetal tissue donation for research. A better understanding of pregnant individuals' views on this topic may lead to policies and practices that are congruent with the needs and values of people facing decisions regarding the disposition of fetal remains.

Leveraging the Massachusetts perinatal quality collaborative to address the COVID-19 pandemic among diverse populations.

OBJECTIVE: We leveraged the Massachusetts perinatal quality collaborative (PQC) to address the COVID-19 pandemic. Our goals were to: (1) implement perinatal practices thought to reduce mother-to-infant SARS-CoV-2 transmission while limiting disruption of health-promoting practices and (2) do so without inequities attributable to race/ethnicity, language status, and social vulnerability. METHODS: Main outcomes were cesarean and preterm delivery, rooming-in, and breastfeeding. We examined changes over time overall and according to race/ethnicity, language status, and social vulnerability from 03/20-07/20 at 11 hospitals. RESULTS: Of 255 mothers with SARS-CoV-2, 67% were black or Hispanic and 47% were non-English speaking. Cesarean decreased (49% to 35%), while rooming-in (55% to 86%) and breastfeeding (53% to 72%) increased. These changes did not differ by race/ethnicity, language, or social vulnerability. CONCLUSIONS: Leveraging the Massachusetts PQC led to rapid changes in perinatal care during the COVID-19 crisis in a short time, representing a novel use of statewide PQC structures.

Advancing research in pregnancy during COVID-19: Missed opportunities and momentum in the US.

Pregnant people's exclusion from COVID-19 vaccine research highlights both the harms of excluding pregnant people from clinical trials and the growing public support for their equitable inclusion. Protectionary tendencies must be challenged for the sake of progress. The COVID-19 pandemic presents an opportunity to translate recognition of an unjust paradigm into action.

Third trimester stillbirth during the first wave of the SARS-CoV-2 pandemic: Similar rates with increase in placental vasculopathic pathology.

Whether early SARS-CoV-2 definitively increases the risk of stillbirth is unknown, though studies have suggested possible trends of stillbirth increase during the pandemic. This study of third trimester stillbirth does not identify an increase in rates during the first wave of the pandemic period, however investigation of the placental pathology demonstrates trends towards more vascular placental abnormalities.

Feedback Focused: A Learner- and Teacher-Centered Curriculum to Improve the Feedback Exchange in the Obstetrics and Gynecology Clerkship.

Introduction: Learners consistently report insufficient feedback, despite interventions to improve the quantity and quality of feedback. Effective feedback requires a dynamic partnership and a trusting relationship between students and teachers. Methods: We developed and implemented a faculty and student program called Feedback Focused on the OB/GYN clerkship with learner- and faculty-centered teaching materials. We evaluated the curriculum's impact on the frequency and quality of feedback exchange through comparison of end-of-clerkship evaluations before and after implementing the Feedback Focused program and assessed student satisfaction from written responses on clerkship evaluations. Results: A total of 1,912 feedback folio entries were recorded during the curriculum timeframe, representing an average of 19 entries per student. Of students, 85% turned in their feedback folios at the end of the clerkship. There was a marked increase in reported frequency of feedback with the initiative, with 28% of students reporting receiving feedback four or more times per month before the start of our program, compared to 64% after its completion. The percentage of students who reported faculty provided direction and constructive feedback always or very often remained roughly the same before and after the program (69% vs. 70%, respectively). Over 60% of students provided positive feedback on written open response questions. Discussion: We successfully developed and implemented a multipronged approach to effectively change the learning environment culture within our OB/GYN clerkship program. Our evaluation demonstrated that the Feedback Focused program was well received and increased frequency of feedback.