Gynecologic Surgery and Obstetrics Leadership Roles in Academic Military Treatment Facilities by Subspecialty and Gender.

INTRODUCTION: Gender distribution in academic ob-gyn leadership positions has previously been examined in the civilian sector, but not in military medicine. OBJECTIVE: To characterize the distribution of department-level leadership positions by gender and subspecialty in academic military facilities in comparison to those reported in the civilian sector. METHODS: This is an observational cross-sectional study. We queried military obstetrics and gynecology (ob-gyn) specialty consultants, for title and gender of personnel assigned to academic military treatment facilities. Roles were characterized by gender and subspecialty, and the proportion of female leaders was compared to published civilian leadership data. RESULTS: Women comprised 25% of Department Chairs, 45% of Assistant Chairs, and 42% of Division Directors. In educational leadership roles, women comprised 25% of Residency Program Directors, 0% of Fellowship Directors, and 62% of medical Student Clerkship Directors. Female department chairs were most often uro-gynecologists (44%) followed by specialists in ob-gyn (37%). Most female residency program directors were specialists in general obstetrics and gynecology. The proportion of women in leadership roles in military departments was not different than in the civilian sector. CONCLUSION: In contrast to civilian academic leadership positions, Department Chairs were most likely to be uro-gynecologists. Similar to civilian programs, women remain underrepresented as chairs, Assistant Chairs, Fellowship Directors, and Division Directors and similarly represented as Residency Program Directors. Despite a smaller pool of women available to fill academic leadership positions in military ob-gyn departments, the proportion of women in leadership roles reaches parity with the civilian sector. This suggests that a greater proportion of women rise to leadership positions in military academic ob-gyn departments than in the civilian sector.

Infant Feeding Practices, Workplace Breastfeeding/Lactation Practices, and Perception of Unit/Service Support Among Primiparous Active Duty Servicewomen.

INTRODUCTION: Successful breastfeeding provides multiple health benefits to Servicewomen and their infants and has positive indirect benefits to the military. Workplace lactation support influences breastfeeding continuation after a Servicewoman's return to work. MATERIALS AND METHODS: This study evaluated the breastfeeding practices and workplace breastfeeding support among primiparous women serving in the U.S. Army. The study was a subanalysis of a non-blinded randomized controlled trial designed to determine the effect of postpartum appointment timing (either 2-3 or 6-8 weeks after delivery) on breastfeeding rates 6 months post-delivery. Subanalysis results were obtained through a telephonic follow-up survey 5-6 months after delivery; Servicewomen were queried to assess their breastfeeding/lactation practices and perception of unit and service support. RESULTS: Eighty of the 97 (82.5%) enrolled Servicewomen participated in the survey. Among respondents, 43.8% were still breastfeeding and 93.6% of those indicated an intent to breastfeed for a duration of 6 months or longer. Among respondents who provided feedback on their workplace, unit, and Army support for breastfeeding/lactation, only 13% reported they had access to a private room, sink, and refrigerator; 53% of respondents felt "mostly" or "very" supported by their assigned unit and 50% felt "mostly" or "very" supported by the Army. CONCLUSION: While almost half of the respondents were still breastfeeding and planned to continue 5-6 months postpartum and the majority of respondents felt "mostly" or "very" supported in their breastfeeding by their unit and the Army, comprehensive physical support for lactation in the workplace was inconsistent. This study provides feedback to inform ongoing implementation of the existing Army breastfeeding support directive.

Effect of Follow-Up Intervals on Breastfeeding Rates 5-6 Months Postpartum: A Randomized Controlled Trial.

OBJECTIVE: To compare the effect of early versus traditional postpartum follow-up intervals on breastfeeding continuation rates 6 months postpartum. METHODS: This randomized controlled trial enrolled primiparous women planning to breastfeed to a postpartum appointment either 2-3 weeks or 6-8 weeks after delivery. The primary outcome was the breastfeeding rate in each group 5-6 months after delivery. The study was powered to detect a 50% difference between groups assuming a 34% rate of breastfeeding at 6 months. Participants were contacted by phone 5-6 months after delivery to assess outcomes. RESULTS: From March 2014 to July 2016, 649 women were screened and 344 enrolled as follows: 172 to 2-3 week and 172 to 6-8 week follow-up. Demographic, delivery, and support characteristics were similar between groups; however, average infant birth weight and the distribution of gestational ages at the time of delivery were different between groups (p < 0.05). Participants in the 2-3 week group had a breastfeeding rate of 57.7% 6 months following delivery and participants in the 6-8 week group had a rate of 59.3%. Early follow-up was associated with a relative risk of 0.97 (95% CI 0.79-1.19, p = 0.80) and an adjusted relative risk of 1.45 (95% CI 0.71-2.95, p = 0.31), when adjusted for confounding variables, for breastfeeding continuation at 5-6 months. CONCLUSIONS: Breastfeeding rates at 5-6 months postpartum were comparable between both groups; early follow-up was not associated with an increased rate of breastfeeding. At 6 months postpartum, the breastfeeding rate in both groups approximated the Surgeon General's Healthy People 2020 goal of 60.6%. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov (Identifier NCT02221895).

Women's Health and Contraceptive Practices of Army Physician Assistants.

INTRODUCTION: Women's roles continue to increase within the U.S. Army. Medical readiness contributes to individual readiness and supports the Army's warfighting mission. Army physician assistants are often the first-line medical providers for Soldiers and their practices, including women's health practices, should support optimal Soldier readiness. Our objective was to survey Army physician assistants' knowledge and practices related to female reproductive health care. MATERIALS AND METHODS: This was a descriptive survey-based study of Army physician assistants conducted from February to June 2017. This study was an addendum to a prior study examining women's health care knowledge and skills among physicians serving as general medical officers. Surveys were distributed via e-mail. The survey was anonymous and included 22 questions describing provider knowledge and practices in the areas of family planning and women's health screening. RESULTS: Out of 198 distributed surveys, 100 (51%) were returned. Most respondents were male (67%), 75% practiced in a troop-based medical clinic, and 73% had current or past practice experience in a military operational/deployed environment. The majority of respondents indicated that they provide family planning services to their reproductive-aged female patients. Combined hormonal contraceptives and depo-medroxyprogesterone had the highest percentage of respondents who reported comfort discussing the method. The highest percentage of respondents indicated discomfort discussing the copper intrauterine device and emergency contraception. Only 10, 17, and 33% of respondents were trained to place the copper intrauterine device, levonorgestrel intrauterine device, and etonogestrel contraceptive implant, respectively. Most respondents offered cervical cancer (74%) and chlamydia (91%) screening to their female patients. CONCLUSION: Most study respondents practiced in a troop-based primary care clinic and most reported experience as a deployed health care providers. Although most respondents indicated comfort discussing combined hormonal contraception and depo medroxyprogesterone, fewer reported comfort discussing long-acting reversible and emergency contraception. Only a minority of respondents reported prior training to place the copper or levonorgestrel intrauterine device or contraceptive implant and, of those trained, most had not placed a device for which they were trained in the preceding 12 months. Chlamydia and cervical cancer screening were offered by most respondents but was not universally offered among the respondents. These findings are consistent with our previous study evaluating women's health knowledge among general medical officers and highlight a need for improved training in the field of women's health for physician assistants serving the active duty population.

A Survey of Family Planning Training, Knowledge, and Practices Among Health Care Providers Within the Military Health System at Joint Base Lewis-McChord.

INTRODUCTION: Within the active duty U.S. military population, the age-adjusted unintended pregnancy rate is higher than the national average. Unplanned pregnancy within the military impacts individual and unit medical readiness. Contraceptive education and availability are means to reduce unintended pregnancy rates; health care providers are key facilitators in provision of contraception. Understanding provider knowledge and practices related to contraceptive provision may identify strengths and gaps in order to provide focal points for sustainment or improvement in family planning practices. The purpose of this study was to assess family planning knowledge, training, and practices among health care providers serving military and dependent beneficiaries within the military health care system at Fort Lewis, Washington. MATERIAL AND METHODS: This was a cross-sectional survey of health care providers on Joint Base Lewis-McChord in Tacoma, Washington who deliver health care services to U.S. uniformed service members and their dependents in varied settings, including outpatient clinics and a tertiary care center. The survey included questions regarding prior contraceptive training, and current contraceptive knowledge and practices. Survey results were evaluated using descriptive and bivariate analyses. The study was approved by both Institutional Review Boards at Emory University and at Madigan Army Medical Center. RESULTS: Overall, 79 eligible health care providers completed the survey. Eighty-six percent of women's health providers consistently ("always or most of the time") provided family planning services to female service members, compared with 38% of primary care providers. Women's health providers were more likely to counsel by method effectiveness and adapt their counseling to consider patients' reproductive life plans. There were no differences between provider type in considering service members' deployment status during contraceptive counseling. Overall, providers identified the correct effectiveness of long-acting contraceptive methods, but tended to overestimate the effectiveness of short-acting methods. CONCLUSIONS: Family planning services available to service members may be improved through enhanced provider education, targeting efficacy-based counseling and identification of barriers to access and provision of long-acting reversible contraceptive methods.

The Incidence of Intrauterine Device Provision in a Military Tertiary Care Facility From 2008-2014 Correlated to Contemporary Contraception Guidelines.

OBJECTIVE: To compare the incidence of intrauterine device (IUD) provision within the beneficiary population of a military tertiary care facility from 2008 to 2014 and in correlation with the publication of landmark contemporary guidelines for contraceptive use. METHODS: This was a retrospective observational study conducted in a military tertiary care facility using coding data to examine the trend in IUD provision correlated with published contraceptive practice guidelines from November 2008 to December 2014. The incidence of device provision was calculated per 1,000 female beneficiaries more than the age of 14 per month. The primary outcome was the mean monthly incidence of IUD in correlation with publication of the U.S. Medical Eligibility Criteria for Contraceptive Use (2010) and the Practice Guidelines from the American College of Obstetricians and Gynecologists (2011). For the subset of provisions that occurred by Family Medicine providers, the American Academy of Family Physicians (2012) was the second comparison clinical guideline. RESULTS: A total of 3,950 IUDs were placed during the study period. There was a statistically significant increase in the overall mean monthly incidence of IUD placement from 0.48 (SE 0.04) before guideline publication to 1.96 (SE 0.07) after the publications (analysis of variance, p < 0.01). Each publication was associated with a statistically significant sequential increase in the incidence of IUD provision. The incidence of provision remained elevated above baseline levels (range 0.93-3.03) for the 34 studied months after the 2011 American College of Obstetricians and Gynecologists Practice Guideline. CONCLUSION: The incidence of IUD provision significantly increased during the study period and in association with published guidelines guiding contraceptive management.

Appraising Medical Literature: The Effect of a Structured Journal Club Curriculum Using The Lancet Handbook of Essential Concepts in Clinical Research on Resident Self-Assessment and Knowledge in Milestone-Based Competencies.

BACKGROUND: Training in literature appraisal and statistical interpretation is one of the residency training requirements outlined by the Accreditation Council for Graduate Medical Education. Frequently, a journal club format is used to teach this competency although this teaching modality is not standardized or well studied in regard to its efficacy. METHODS: This study sought to determine the effect of a structured journal club curriculum that incorporated The Lancet Handbook of Essential Concepts in Clinical Research on objective and self-assessed knowledge pertaining to study design and interpretation. The study was a retrospective observational study evaluating the effect of a structured journal club curriculum using the Lancet text with pre- and postimplementation assessment using a resident self-assessment survey. The study examined a monthly journal club curriculum that covered 1 topic/chapter from the assigned text, paired with a contemporary article to highlight the chapter topic. Resident self-assessed and objective knowledge was evaluated and compared using a survey taken before and after the curriculum change. The study was completed during 1 academic year at Madigan Army Medical Center in Tacoma, Washington, an academic military medical training and tertiary care center. Study surveys were distributed to all 17 obstetrics and gynecology residents throughout the 4 residency training years. Of the 17 potential participants, 13 (76%) participated in the precurriculum assessment and 14 (82%) participated after its completion. FINDINGS: There was no significant improvement in resident self-assessed knowledge following curriculum implementation. There was a trend toward improved objective knowledge pertaining to study design and interpretation after curriculum completion, but this was not statistically significant. DISCUSSION: There is a lack of standardized and well-studied methods to teach residents how to evaluate and appraise medical literature and research. The Lancet Handbook of Essential Concepts in Clinical Research may be a useful tool to teach some of these tenets in the residency training environment, but this limited study did not prove this assertion. IMPACT: Three is a dearth of proven and well-studied means to teach the tenets of study design, statistical interpretation, and critical literature appraisal to trainees with any consistency or validity. This study demonstrated a trend toward better objective knowledge related to study design, interpretation, and understanding after a change in our training curriculum that implemented The Lancet Handbook of Essential Concepts in Clinical Research into the monthly journal club curriculum. Resident self-rated knowledge and proficiency in their abilities to understand research and study design were not significantly changed with the curriculum. RECOMMENDATIONS: Better evidence is needed to guide future educational curricula directed toward teaching the competency of medical literature review and appraisal.

Women's Health Knowledge and Skills Among Transitional Year Internship-Trained Military Medical Officers Serving as Independent Health Care Providers.

BACKGROUND: Women comprise 14.5% of active duty service members. Delivery of women's health services is a critical component to personal, medical, and mission readiness. Our objective was to evaluate the knowledge, skills, and practices pertaining to basic elements of women's/reproductive health issues among transitional internship-trained general medical officers in the Army, Navy, and Air Force. MATERIALS AND METHODS: This is a cross-sectional survey study of transitional internship-trained graduates from 2012 to 2015 who transitioned to an operational assignment as an independent provider after internship graduation. The study involved an anonymous 21-question survey evaluating aspects of knowledge and practice related to basic reproductive health care services (contraceptive provision, cervical cancer, and chlamydia screening). RESULTS: Thirty-four of 62 (55%) eligible physicians completed the survey. The majority (85%) of respondents were male; 71% practiced at troop or unit-based clinic outside a hospital setting. Among the respondents, 97% cared for female service members within their patient population; one respondent (3%) reported no female service members in their patient population. Most respondents (82%) reported provision of contraceptive services to female patients of reproductive age. The copper intrauterine device (IUD) was least comfortably discussed. Less than half of the respondents were trained to place either the copper or levonorgestrel IUD or the etonogestrel contraceptive implant. Seventy-six percent of respondents performed cervical cancer screening and 79% performed chlamydia screening in their female patient population. Among the respondents, 15% did not offer cervical cancer and 12% did not offer chlamydia screening in their practice. Eighty-eight percent of the respondents correctly identified the recommended age at which to begin cervical cancer screening and 64% correctly identified the aged-based recommendation and interval to screen for chlamydia. CONCLUSION: Our survey conveyed that the majority of respondents were comfortable discussing self-administered methods (combined contraceptives); fewer were comfortable discussing or had training to place the more efficacious, longer-acting methods. Although screening services specific to female health are offered, the uniform provision of these basic services appears to be inconsistent among our surveyed population of first-line health care providers. Our study identifies potential areas for refinement in transitional year medical training that could translate to enhanced female medical and mission readiness.

The pregnancy "super-utilizer": how does a high-risk depression screen affect medical utilization?

OBJECTIVE: Our objective was to determine whether a score of >11 on the Edinburgh postnatal depression scale (EPDS) at the initial prenatal visit was associated with an increased use of acute medical visits when compared to pregnant women with an initial EPDS score of ≤11. METHODS: This was a retrospective cohort study comparing the utilization of acute medical care during pregnancy and the first eight weeks after delivery amongst 200 women with an EPDS score >11 at their initial prenatal visit compared with 200 women with an EPDS score ≤11. "Super-utilization" was defined as ≥4 acute or unscheduled medical visits during pregnancy and the first eight weeks after delivery (90th percentile). Logistic regression was used to control for confounders. RESULTS: Women with an initial EPDS score >11 were significantly more likely to engage in super-utilization of acute medical care compared with those women scoring ≤11 (adjusted odds ratio [aOR], 2.12; 95% confidence interval [CI], 1.53-3.90). CONCLUSIONS: Pregnant women scoring >11 on the EPDS at their initial prenatal visit are more likely to super-utilize acute medical care in the perinatal period. This subset of patients at-risk for increased utilization can be identified early during prenatal care. Interventions to better meet the medical and psychosocial needs of these women warrant future research.

Unintended Pregnancy in the Military Health Care System: Who is Really at Risk?

Unintended pregnancy is a global issue and one that is reportedly to be higher in the military population. We sought to assess rates of unintended pregnancy among the active duty population in comparison to other military health care beneficiaries. Using a validated six-question survey, patients aged 18 to 42 were surveyed in five different clinics at three major tertiary hospitals from December 2013 to December 2014. Individual survey questions were scored 0, 1, or 2 and a total score was tabulated. A total score of 0 to 3 indicated unintended pregnancy, 4 to 9 indicated ambivalence toward pregnancy, and 10 to 12 indicated intended pregnancy. Subanalysis was performed on two survey questions specifically looking at pregnancy intentions. A total of 1,211 completed surveys were analyzed. Overall, 6.9% of all respondents had an unintended pregnancy compared to 23% of pregnancies in single active duty women. Single, active duty service members were more likely to indicate they did not intend to get pregnant or want a baby before becoming pregnant. Overall, the rate of unintended pregnancy among military health care beneficiaries is low. However, single active duty women are at significantly higher risk for unintended pregnancy and specifically targeted interventions should be implemented for this population.

Hysteroscopic Sterilization Failure Following Post-Procedure Confirmatory Test Indicating Tubal Occlusion.

BACKGROUND: Hysteroscopic sterilization procedure has gained traction in the past decade as a means of contraception advertised to be 99.83% effective following successful sterilization coil placement and postprocedure hysterosalpingogram confirmation of proper coil positioning and tubal occlusion. CASE: A 44-year-old female underwent a second sterilization procedure after delivering a pregnancy that occurred following a reportedly successful hysteroscopic sterilization procedure and subsequent confirmatory testing demonstrating appropriate sterilization coil placement and tubal occlusion. During the second sterilization procedure, a coil device was visible perforating through the left uterine cornua. CONCLUSION: Following hysteroscopic sterilization, confirmatory testing may demonstrate the appearance of tubal occlusion and proper coil placement when the sterilization devices are incorrectly placed and the fallopian tubes patent.

Pipelle endometrial sampling in the evaluation of abnormal first trimester pregnancies.

OBJECTIVE: To evaluate the utility of pipelle endometrial sampling as a diagnostic tool in the evaluation of abnormal first trimester gestations. METHODS: Thirty-one women with abnormal first trimester pregnancies defined as gestations with abnormally rising or falling quantitative human chorionic gonadotropin (ß-hCG) levels and ultrasound findings consistent with a nonviable or ectopic pregnancy were prospectively evaluated. Endometrial pipelle sampling was performed on each patient in a standardized fashion immediately before curettage and evaluated as a fixed, permanent specimen to assess for the presence of either chorionic villi, trophoblastic or fetal tissue. RESULTS: The sensitivity, specificity, positive predictive value, and negative predictive value for endometrial biopsy were 70.1%, 100%, 100%, and 33.3%, respectively. For curettage, the sensitivity, specificity, positive predictive value, and negative predictive value were 88.9%, 100%, 100%, and 57.1%, respectively. CONCLUSION: Curettage's overall sensitivity is superior to endometrial biopsy in detecting the presence of intrauterine products of conception in early abnormal pregnancies. However, in some clinical situations where the diagnosis of ectopic pregnancy is in question, particularly if the ß-hCG is ≤ 2,000 mIU/mL, endometrial pipelle biopsy could be a useful tool in the evaluation algorithm.

The distribution and predictive value of Bishop scores in nulliparas between 37 and 42 weeks gestation.

OBJECTIVE: The natural distribution and predictive accuracy of Bishop scores was evaluated to predict cesarean delivery (CD) in nulliparas between 37 and 42 weeks gestation. STUDY DESIGN: Subjects underwent serial digital cervical examinations. The Bishop score was evaluated as a binary and continuous factor to predict CD at each gestational week beginning at 37 weeks. Bishop scores were categorized as ≤5 or >5, and CD rates were compared across Bishop score categories using chi-square or Fisher exact tests at each gestational week beginning at 37 weeks. RESULTS: In all, 171 patients were prospectively followed. The overall CD rate was 27.5%. The prevalence of unfavorable Bishop scores, categorized as ≤5, decreased with increasing gestation age until 41 weeks. CD rates for the cohort with unfavorable Bishop scores was higher than those with favorable scores at each week. The likelihood ratio for CD was 1.35-2.00, depending on gestational age. The Bishop score that best predicted subsequent vaginal delivery following expectant management was >3 at 37 weeks and >5 at 39 weeks. CONCLUSION: A Bishop score ≤5 between 37 and 39 weeks gestation predicts a higher CD rate compared to patients with a Bishop score >5 implying an intrinsically higher CD risk despite expectant management.