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Objectives: Intra-Uterine Device (IUD) insertion is possible in early postpartum. Although this contraception method is recognized and used in lots of country, it seems infrequent and poorly known in France. Our study aims to assess the barriers to the application of this method in France., Methods: A questionnaire was sent to obstetricians-gynaecologist professionals and midwives in France, through the affiliation to CNGOF (French National College of Obstetricians and Gynecologists) and to CNSF (French National College of Midwives). Questions were focused on the practices and knowledge about the insertion of IUD in early postpartum., Results: four hundred eight practitioners responded. Amongst them, 63% knew about the possibility to use IUDs after a vaginal delivery and 31% knew it could be inserted during cesarean section. Ten percent of them used this method. Most of these practitioners (80% of them) would like to discuss the insertion of an IUD in early postpartum with their patients and 71% would like to perform the insertion themselves after training. Besides, this study shows that contraception is rarely addressed by physicians during the follow-up of pregnancies. Less than 15% of respondents report discussing the topic systematically with the patient during the pregnancy follow during pregnancy follow., Conclusion: insertion of IUDs in early postpartum is uncommon in France. The main limitation seems to be a lack of knowledge, but practitioners seem to be interested in this practice. Training courses could be created in order to rase up the adoption of this practice., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Background: We aim to assess competencies (knowledge, skills and attitudes) of midwifery care providers as well as their experiences and perceptions of in-service training in the four study countries; Benin, Malawi, Tanzania and Uganda as part of the Action Leveraging Evidence to Reduce perinatal mortality and morbidity in sub-Saharan Africa project (ALERT). While today more women in low- and middle-income countries give birth in health care facilities, reductions in maternal and neonatal mortality have been less than expected. This paradox may be explained by the standard and quality of intrapartum care provision which depends on several factors such as health workforce capacity and the readiness of the health system as well as access to care., Methods: Using an explanatory sequential mixed method design we will employ three methods (i) a survey will be conducted using self-administered questionnaires assessing knowledge, (ii) skills drills assessing basic intrapartum skills and attitudes, using an observation checklist and (iii) Focus Group Discussions (FGDs) to explore midwifery care providers' experiences and perceptions of in-service training. All midwifery care providers in the study facilities are eligible to participate in the study. For the skills drills a stratified sample of midwifery care providers will be selected in each hospital according to the number of providers and, professional titles and purposive sampling will be used for the FGDs. Descriptive summary statistics from the survey and skills drills will be presented by country. Conventional content analysis will be employed for data analysis of the FGDs., Discussion: We envision comparative insight across hospitals and countries. The findings will be used to inform a targeted quality in-service training and quality improvement intervention related to provision of basic intrapartum care as part of the ALERT project., Trial Registration: PACTR202006793783148-June 17th, 2020.

Background: Breast cancer diagnosed during pregnancy (BCP) is uncommon, and thus there is limited evidence on its treatment. However, the incidence of BCP is increasing probably due to women having children at an older age. We aimed to clarify the practice patterns and limitations in treatment for BCP in Japan., Methods: A cross-sectional survey was developed for board-certified Japanese breast cancer specialists (n = 1583) to evaluate their knowledge, attitude, experience, and practice patterns regarding BCP. Survey items also included questions regarding potential barriers of practice toward patients diagnosed during pregnancy and respondents' background., Results: In March 2018, 492 (31.1%) breast oncologists responded to the survey. Among them, 234 (48%) respondents had the experience of treating at least one case of BCP. The accuracy of knowledge about BCP was evaluated by three items regarding BCP treatment from the latest Japanese Breast Cancer Society treatment guideline, and 265 (54%) were categorized to have "appropriate knowledge". Majority of the physicians (89%) have responded that patients should be treated in a center where both a cancer-treating team and obstetrician exist, and 48% responded that treating patients by the collaboration of cancer-treating team and obstetric team in different institutes is an alternative reasonable option., Conclusions: Interest, knowledge, and awareness of the guidelines appear to influence physician attitude, and thus it is urgently important to lay out educational materials and learning opportunities regarding BCP for breast specialists. A regional network of oncologists, obstetricians, and pediatricians to support the BCP patients should be developed.

Background: Poor quality obstetric and newborn care persists in sub-Saharan Africa and weak provider competence is an important contributor. To be competent, providers need to be both knowledgeable and confident in their ability to perform necessary clinical actions. Confidence or self-efficacy has not been extensively studied but may be related to individuals' knowledge, ability to practice their skills, and other modifiable factors. In this study, we investigated how knowledge and scope of practice are associated with provider confidence in delivering obstetric and newborn health services in Uganda and Zambia., Methods: This study was a secondary analysis of data from an obstetric and newborn care program implementation evaluation. Provider knowledge, scope of practice (completion of a series of obstetric tasks in the past 3 months) and confidence in delivering obstetric and newborn care were measured post intervention in intervention and comparison districts in Uganda and Zambia. We used multiple linear regression models to investigate the extent to which exposure to a wider range of clinical tasks associated with confidence, adjusting for facility and provider characteristics., Results: Of the 574 providers included in the study, 69% were female, 24% were nurses, and 6% were doctors. The mean confidence score was 71%. Providers' mean knowledge score was 56% and they reported performing 57% of basic obstetric tasks in the past 3 months. In the adjusted model, providers who completed more than 69% of the obstetric tasks reported a 13-percentage point (95% CI 0.08, 0.17) higher confidence than providers who performed less than 50% of the tasks. Female providers and nurses were considerably less confident than males and doctors. Provider knowledge was moderately associated with provider confidence., Conclusions: Our study showed that scope of practice (the range of clinical tasks routinely performed by providers) is an important determinant of confidence. Ensuring that providers are exposed to a variety of services is crucial to support improvement in provider confidence and competence. Policies to improve provider confidence and pre-service training should also address differences by gender and by cadres.

Background: Clinical learning environments influence the learning and performance of learners by creating learning opportunities and experiences. The maternity ward offers a major educational opportunity for midwifery students, obstetrics and gynecology residents and medical interns to acquire and improve crucial skills., Objectives: This study seeks to determine the way in which the clinical learning environment of the maternity ward creates learning opportunities and enables the accumulation of experiences for the noted learners., Methods: This qualitative study was conducted using inductive content analysis at the Maternity Ward of Shahid Beheshti Hospital, affiliated with University of Medical Sciences. Midwifery students, medical interns and obstetrics and gynecology residents spend a certain period of time in this ward as a mandatory part of their obstetrics and gynecology training. Data were collected through semi-structured individual interviews and observations and were then analyzed in MAXQDA concurrently with data collection., Results: Three main categories emerged from the analysis of the data collected from the interviews and observations: disorganized learning opportunities, heavy emotional load and learners' abandonment in the care-provider and learner role., Conclusion: The maternity ward lacked the necessary organization to generate an environment conducive to learning and independent practice for the three groups of learners. The learners' training and acquired skills were thus affected by the clinical learning environment., (Copyright © 2019. Published by Elsevier Ltd.)

Objective: To measure future and current resident perspectives on obstetrics and gynecology residency training structure and possible future models., Methods: Medical students invited for obstetrics and gynecology residency interviews and residents (postgraduate year [PGY]-1-4) at the University of Colorado, the University of Washington, the University of California San Francisco, Loyola University, Saint Joseph's Hospital, and Texas A&M in 2017-2018 received a voluntary, electronic survey regarding possible models for restructuring residency training. Student and resident responses were compared using χ test for categorical and two-sample t-test for continuous items., Results: Applicants (63%, 280/444) and residents (66%, 101/153) had similar response rates (overall response rate 64%). Applicants (24%) and residents (29%) reported having concerns about the current structure of residency training. The ideal residency duration was reported as 4 years by 72% of applicants and 85% of residents. Lack of gynecologic surgical volume was the most frequently reported concern among applicants (75%) and residents (72%). Fourth-year tracking (focusing on training aligned with postgraduation career path) was preferred by 90% of applicants and 77% of residents (P=.002) and 92% among respondents planning fellowship. Most applicants (68%) and residents (75%) preferred not starting fellowship training after the 3rd year of residency., Discussion: The majority of learners surveyed support a 4-year training structure but likewise support individualizing training in PGY-4. It is imperative that obstetrics and gynecology leadership consider this and other feedback from learners when considering modifications to the current training paradigm.

Residency programs across the United States are searching for ways to improve surgical skills and operative experiences in obstetrics and gynecology residencies. We developed an obstetrics and gynecology residency program that offers a flexible curriculum, referred to as tracking, to address these needs. Curriculum content was developed using a modified Delphi method, using input from experts in medical education and obstetrics and gynecology. Outcome data were collected on trainees who graduated between 2016 and 2019, including postgraduate fellowship placement and our residents' achievement of surgical minimum requirements based on procedure logs. Trainees from this program have consistently exceeded minimal surgical requirements in all areas, regardless of tracking preference. Since the beginning of the program in 2012, more than 60% of graduates have matriculated into fellowships. Flexible curricula, such as tracking, offer one approach to a changing climate of medicine. The ability to offer flexible, focused, and individualized training is an approach with great potential to produce graduates who excel in all areas of obstetrics and gynecology while sharpening skills specific to their areas of interest.

Objective: Little is known about how teams' non-technical performance influences clinical performance in obstetric emergencies such as postpartum haemorrhage., Design: Video review - observational study., Setting: A university hospital (5000 deliveries) and a regional hospital (2000 deliveries) in Denmark., Population: Obstetric teams managing real-life postpartum haemorrhage., Methods: We systematically assessed 99 video recordings of obstetric teams managing real-life major postpartum haemorrhage. Exposure was the non-technical score (AOTP); outcomes were the clinical performance score (TeamOBS) and the delayed transfer to the operating theatre (defined as blood loss >1500 ml in the delivery room)., Results: Teams with an excellent non-technical score performed significantly better than teams with a poor non-technical score: 83.7 versus 0.3% chance of a high clinical performance score (P < 0.001), 0.2 versus 80% risk of a low clinical performance score (P < 0.001), and 3.5 versus 31.7% risk of delayed transfer to the operating theatre (P = 0.008). The results remained robust when adjusting for potential confounders such as bleeding velocity, aetiology, time of day, team size, and hospital. The specific non-technical skills associated with high clinical performance were vigilance, role assignment, problem-solving, management of disruptive behavior, and leadership. Communication with the patient and closing the loop were of minor importance. All performance assessments showed good reliability: the intraclass correlation was 0.97 (95% CI 0.96-0.98) for the non-technical score and 0.84 (95% CI 0.76-0.89) for the clinical performance score., Conclusion: Video review offers a new method and new perspectives for research in obstetric teams to identify how teams become effective and safe; the skills identified in this study can be included in future obstetric training programmes., Tweetable Abstract: Non-technical performance is important for teams managing postpartum haemorrhage; video review of 99 obstetric teams., (© 2019 Royal College of Obstetricians and Gynaecologists.)

Objective: To assess the existing knowledge and skills relating to Emergency Obstetrics Care (EMOC) among health providers in eight referral maternity hospitals in Nigeria., Study Design: A cross-sectional study of skilled health providers (doctors, nurses and midwives) working in the hospitals during the period., Setting: Six general hospitals (4 in the south and 2 in the north), and two teaching hospitals (both in the Northern part) of the country., Population: All skilled providers offering EMOC services in the hospitals during the study., Methods: A pre-tested self-administered questionnaire was used to obtain information relating to socio-demographic characteristics, the respondents' knowledge and skills in offering specific EMOC services (as compared to standard World Health Organization recommendations), and their confidence in transferring the skills to mid-level providers. Data were analyzed with univariate, bivariate, binary and multinomial logistic regression analyses. Main outcome measures: knowledge and skills in EMOC services by hospital and overall., Results: A total of 341 health providers (148 doctors and 193 nurses/midwives) participated in the study. Averagely, the providers scored less than 46% in a composite EMOC knowledge score, with doctors scoring considerable higher than the nurses/midwives. Similarly, doctors scored higher than nurses/midwives in the self-reporting of confidence in carrying out specific EMOC functions. Health providers that scored higher in knowledge were significantly more likely to report confidence in performing specific EMOC functions as compared to those with lower scores. The self-reporting of confidence in transferring clinical skills was also higher in those with higher EMOC knowledge scores., Conclusion: The knowledge and reported skills on EMOC by health providers in referral facilities in Nigeria was lower than average. We conclude that the in-service training and re-training of health providers should be included in national policy and programs that address maternal mortality prevention in referral facilities in the country., Trial Registration: Nigeria Clinical Trials Registry 91540209., Competing Interests: The authors have declared that no competing interests exist.

Purpose of Review: The purpose of this review is to outline surgical skills assessment tools for the purpose of training and competency evaluation, with a focus on recent literature in gynecology., Recent Findings: Objective standardized surgical skills assessment tools are increasingly being explored in multiple surgical disciplines including gynecology. Several small studies in gynecology have validated procedure-specific checklists, global rating scales, and other surgical proficiency examinations in their ability to differentiate trainee skill level or correlate with other standardized tests. Few studies have included gynecologic surgeons in practice, and no studies have investigated their use in credentialing and maintenance of certification., Summary: Surgical skills assessment tools may be a useful adjunct to gynecology training programs, with promising applications for practicing gynecologists.

Background: Poor emergency obstetric care has been shown by national confidential enquiries into maternal deaths to contribute to a number of maternal deaths in South Africa., Objectives: To assess whether a structured training course can improve knowledge and skills and whether this can influence the capacity of a healthcare facility to provide basic and comprehensive emergency obstetric care signal functions., Methods: A baseline survey was conducted to assess the seven basic emergency obstetric and neonatal care signal functions in 51 community health centres (CHCs) and the nine comprehensive emergency care signal functions in 62 district hospitals (DHs). A re-assessment was conducted 1 year after saturation training had been provided in each district. The delegates were trained using a structured training programme (Essential Steps in Managing Obstetric Emergencies, ESMOE) and their knowledge and skills were tested before and after the training. Saturation training was considered to have been achieved once 80% of the healthcare professionals involved in maternity care had been trained., Results: There was a significant improvement in the knowledge and skills of doctors, namely by 16.8% and 32.8%, respectively, of advanced midwives by 13.7% and 29.0%, and of professional nurses with midwifery by 16.1% and 31.2%. The seven basic emergency care functions improved from 60.8% to 67.8% in the CHCs and from 90.7% to 92.5% in the DHs before and after training. If the two signal functions that are not within the scope of practice of professional nurses with midwifery are excluded (viz. assisted delivery and manual vacuum aspiration), the functionality of CHCs increased from 85.1% to 94.9%., Conclusions: The ESMOE training programme improved knowledge and skills, but there was a modest improvement in the functionality of the facilities. Improvement in functionality requires changes in the structure of the health system, including changing the scope of practice of professional nurses with midwifery and employing more advanced midwives in CHCs.

Objective: To identify the factors associated with quality decision-making of healthcare professionals in managing complicated labour and delivery in referral hospitals of Burkina Faso., Methods: We carried out a six-month observational cross-sectional study among 123 healthcare professionals performing caesareans in 22 hospitals. Clinical decision-making was evaluated using hypothetical patient vignettes framed around four main complications during labour and delivery and developed using guidelines validated by an expert committee. The results were used to generate a quality decision-making score. A multivariate linear regression analysis was used to identify the factors independently associated with the score., Results: Out of 100, the mean ± SD quality decision-making score was 63.84 ± 7.21 for midwives, 65.58 ± 6.90 for general practitioners (GPs), and 71.94 ± 6.70 for gynaecologist-obstetricians (p < 0.001). Quality decision-making score was higher among professionals with more than seven years' work experience and those with the highest level of professional qualification. Working in a service where partograms are regularly reviewed by peers dramatically increased the skills of professionals., Conclusion: The simple dissemination of written clinical guidelines is not sufficient to maintain high-quality decision-making among healthcare professionals in Burkina Faso. Midwives may have some better scores than GPs if duly retrained and supervised. Increasing in-service training and supervision of both junior staff and lower-qualified healthcare professionals might help to improve obstetric practices in referral hospitals of Burkina Faso., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Ultrasound imaging has become integral to the practice of obstetrics and gynecology. With increasing educational demands and limited hours in residency programs, dedicated time for training and achieving competency in ultrasound has diminished substantially. The American Institute of Ultrasound in Medicine assembled a multi-Society Task Force to develop a consensus-based, standardized curriculum and competency assessment tools for obstetric and gynecologic ultrasound training in residency programs. The curriculum and competency-assessment tools were developed based on existing national and international guidelines for the performance of obstetric and gynecologic ultrasound examinations and thus are intended to represent the minimum requirement for such training. By expert consensus, the curriculum was developed for each year of training, criteria for each competency assessment image were generated, the pass score was established at or close to 75% for each, and obtaining a set of five ultrasound images with pass score in each was deemed necessary for attaining each competency. Given the current lack of substantial data on competency assessment in ultrasound training, the Task Force expects that the criteria set forth in this document will evolve with time. The Task Force also encourages use of ultrasound simulation in residency training and expects that simulation will play a significant part in the curriculum and the competency-assessment process. Incorporating this training curriculum and the competency-assessment tools may promote consistency in training and competency assessment, thus enhancing the performance and diagnostic accuracy of ultrasound examination in obstetrics and gynecology. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd., (© 2018 jointly by the International Society of Ultrasound in Obstetrics and Gynecology, the American Institute of Ultrasound in Medicine, and Elsevier Inc. All rights reserved.)

Introduction: We aimed to examine whether cardiotocography (CTG) knowledge, interpretation skills and decision-making measured by a written assessment were associated with size of maternity unit, years of obstetric work experience and healthcare professional background., Material and Methods: A national cross-sectional study in the setting of a CTG teaching intervention involving all 24 maternity units in Denmark. Participants were midwives (n = 1260) and specialists (n = 269) and residents (n = 142) in obstetrics and gynecology who attended a 1-day CTG course and answered a 30-item multiple-choice question test. Associations between mean test score and work conditions were analyzed using multivariable robust regression, in which the three variables were mutually adjusted., Results: Participants from units with > 3000 deliveries/year scored higher on the test than participants from units with < 1000 deliveries/year (3000-3999 deliveries/year: mean difference 0.8, p < 0.0001; > 4000 deliveries/year: mean difference 0.5, p = 0.006). Participants with < 15 years of work experience scored higher than participants with > 15 years of experience (15-20 years of experience: mean difference - 0.6, p = 0.007; > 20 years experience: mean difference - 0.9, p < 0.0001). No differences were detected concerning professional background., Conclusions: CTG knowledge, interpretation skills and decision-making measured by a written assessment were positively associated with working in large maternity units and having < 15 years of obstetric work experience. This might indicate a challenge in maintaining CTG skills in small units and among experienced staff but could also reflect different levels of motivation, test familiarity and learning culture. Whether the findings are transferable to the clinical setting was not examined., (© 2017 Nordic Federation of Societies of Obstetrics and Gynecology.)

Background: The question of assessing surgical competence is the focus of mainly Anglo-Saxon studies. The GOALS questionnaire (Global Operative Assessment of Laparoscopic Skills) specific to laparoscopic surgery assessment has been developed since 2005. The aim of the study was to assess the metrological qualities of the GOALS questionnaire after ratification in French language., Methods: To produce a French version of the GOALS surgical competence assessing tool according to an established method (translation - backward translation - retranslation) and to check the metrological qualities (user satisfaction, acceptability, reliability and validity) of this questionnaire through observing residents while in training program on 22 residents in Gynaecology Obstetrics during the laparoscopy training, with the performance of a nephrectomy on a porcine model., Results: The discrepancies in the initial translations were mainly due literal translations. Only synonymous differences were observed in the two backward translations. Comparison with original version led to 8 minor changes. No changes occurred between the 2 French versions. Satisfaction surveys when using the GOALS questionnaire by both examiners and students are similar. Face and content validity seemed good and there is no significant discrepancy between the examiners and the students (11.5 [9-15]; 12.4 [9-15]; P=0.40). Assessment by examiners showed an median value of 17.8 [9-26] with good correlation (α=0.80). By contrast, self-assessment, although there is no significant discrepancy, showed heterogeneity. GOALS French version was able to prove a significant progression both in self-assessment and external evaluation between the act performed on the first nephrectomy on the first day of the first session of the training and the fourth nephrectomy performed on the first day of the second session of the training., Conclusion: Our work allowed obtaining a GOALS French version with acceptable validity, good consistency between the assessments and ability to measure progress., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Teamwork performance is an essential component for the clinical efficiency of multi-professional teams in obstetric care. As patient safety is related to teamwork performance, it has become an important learning goal in simulation-based education. In order to improve teamwork performance, reliable assessment tools are required. These can be used to provide feedback during training courses, or to compare learning effects between different types of training courses. The aim of the current study is to (1) identify the available assessment tools to evaluate obstetric teamwork performance in a simulated environment, and (2) evaluate their psychometric properties in order to identify the most valuable tool(s) to use. We performed a systematic search in PubMed, MEDLINE, and EMBASE to identify articles describing assessment tools for the evaluation of obstetric teamwork performance in a simulated environment. In order to evaluate the quality of the identified assessment tools the standards and grading rules have been applied as recommended by the Accreditation Council for Graduate Medical Education (ACGME) Committee on Educational Outcomes. The included studies were also assessed according to the Oxford Centre for Evidence Based Medicine (OCEBM) levels of evidence. This search resulted in the inclusion of five articles describing the following six tools: Clinical Teamwork Scale, Human Factors Rating Scale, Global Rating Scale, Assessment of Obstetric Team Performance, Global Assessment of Obstetric Team Performance, and the Teamwork Measurement Tool. Based on the ACGME guidelines we assigned a Class 3, level C of evidence, to all tools. Regarding the OCEBM levels of evidence, a level 3b was assigned to two studies and a level 4 to four studies. The Clinical Teamwork Scale demonstrated the most comprehensive validation, and the Teamwork Measurement Tool demonstrated promising results, however it is recommended to further investigate its reliability., (Copyright © 2017. Published by Elsevier B.V.)

Background: Postpartum hemorrhage (PPH) is a major cause of maternal morbidity and mortality. In Tanzania, PPH causes 25% of maternal deaths. Skilled attendance is crucial to saving the lives of mothers and their newborns during childbirth. This study is a follow-up after multi-professional simulation training on PPH in northern Tanzania. The purpose was to enhance understanding and gain knowledge of important learning features and outcomes related to multi-professional simulation training on PPH., Methods: The study had a descriptive and exploratory design. After the second annual simulation training at two hospitals in northern Tanzania, ten focus group discussions comprising 42 nurse midwives, doctors, and medical attendants, were carried out. A semi-structured interview guide was used during the discussions, which were audio-taped for qualitative content analysis of manifest content., Results: The most important findings from the focus group discussions were the importance of team training as learning feature, and the perception of improved ability to use a teamwork approach to PPH. Regardless of profession and job tasks, the informants expressed enhanced self-efficacy and reduced perception of stress. The informants perceived that improved competence enabled them to provide efficient PPH management for improved maternal health. They recommended simulation training to be continued and disseminated., Conclusion: Learning features, such as training in teams, skills training, and realistic repeated scenarios with consecutive debriefing for reflective learning, including a systems approach to human error, were crucial for enhanced teamwork. Informants' confidence levels increased, their stress levels decreased, and they were confident that they offered better maternal services after training.

Background: There is evidence that preoperative practice prior to surgery can improve trainee performance, but the optimal approach has not been studied., Objective: We sought to determine if preoperative practice by surgical trainees paired with instructor feedback improved surgical technique, compared to preoperative practice or feedback alone., Methods: We conducted a randomized controlled trial of obstetrics-gynecology trainees, stratified on a simulator-assessed surgical skill. Participants were randomized to preoperative practice on a simulator with instructor feedback (PPF), preoperative practice alone (PP), or feedback alone (F). Trainees then completed a laparoscopic salpingectomy, and the operative performance was evaluated using an assessment tool., Results: A total of 18 residents were randomized and completed the study, 6 in each arm. The mean baseline score on the simulator was comparable in each group (67% for PPF, 68% for PP, and 70% for F). While the median score on the assessment tool for laparoscopic salpingectomy in the PPF group was the highest, there was no statistically significant difference in assessment scores for the PPF group (32.75; range, 15-36) compared to the PP group (14.5; range, 10-34) and the F group (21.25; range, 10.5-32). The interrater correlation between the video reviewers was 0.87 (95% confidence interval 0.70-0.95) using the intraclass correlation coefficient., Conclusions: This study suggests that a surgical preoperative practice with instructor feedback may not improve operative technique compared to either preoperative practice or feedback alone.

Purpose: The aim of this study was to demonstrate the construct and predictive validity of a task-specific checklist for cystoscopy in the operating room., Methods: This study is a prospective observational study evaluating the validity of a task-specific checklist for cystoscopic proficiency on residents performing cystoscopy in the operating room over a 4-year period. Residents were scored on 2 task-specific checklists: (1) assembly and (2) performance of a diagnostic cystoscopy. Construct validity was evaluated by comparing absolute checklist scores based on resident year with a Kruskal-Wallis and χ test, respectively. Paired analysis was performed with Wilcoxon sign rank and McNemar tests to assess differences between initial and final observations. Predictive validity was evaluated by determining the percent of competently performed task-specific checklists subsequent to 1 competent task-specific checklist completion., Results: One hundred fifty-three evaluations were performed on 30 residents from all 4 levels of training. The median task-specific checklist scores for both (1) assembly and (2) performance of a diagnostic cystoscopy demonstrated construct validity with statistically significant trends demonstrating improved scores as resident year increased from intern to chief, P values of <0.001 and <0.0001, respectively. Once competency was obtained for 1 cystoscope assembly checklist, 92% of future assembly checklists were competently competent. For diagnostic cystoscopy once checklist competency was obtained, 69% of future checklists were completed competently. All scores and competencies were significantly improved from the initial to the final observation., Discussion: The task-specific checklists for (1) assembly and (2) performance of a diagnostic cystoscopy demonstrated construct validity. Predicative validity for assembly of a cystoscope is high but less so for performance of a diagnostic cystoscope.

Objective: To investigate the association between student performance in undergraduate objective structured clinical examinations (OSCEs) and the examination schedule to which they were assigned to undertake these examinations., Design: Analysis of routinely collected data., Setting: One UK medical school., Participants: 2331 OSCEs of 3 different types (obstetrics OSCE, paediatrics OSCE and simulated clinical encounter examination OSCE) between 2009 and 2013. Students were not quarantined between examinations., Outcomes: (1) Pass rates by day examination started, (2) pass rates by day station undertaken and (3) mean scores by day examination started., Results: We found no evidence that pass rates differed according to the day on which the examination was started by a candidate in any of the examinations considered (p>0.1 for all). There was evidence (p=0.013) that students were more likely to pass individual stations on the second day of the paediatrics OSCE (OR 1.27, 95% CI 1.05 to 1.54). In the cases of the simulated clinical encounter examination and the obstetrics and gynaecology OSCEs, there was no (p=0.42) or very weak evidence (p=0.099), respectively, of any such variation in the probability of passing individual stations according to the day they were attempted. There was no evidence that mean scores varied by day apart from the paediatric OSCE, where slightly higher scores were achieved on the second day of the examination., Conclusions: There is little evidence that different examination schedules have a consistent effect on pass rates or mean scores: students starting the examinations later were not consistently more or less likely to pass or score more highly than those starting earlier. The practice of quarantining students to prevent communication with (and subsequent unfair advantage for) subsequent examination cohorts is unlikely to be required., Competing Interests: JBe is Director of the GP Education Group, which organises Primary Care teaching in the School of Clinical Medicine. From 2003 to 2013, he was an Associate Dean in the School of Clinical Medicine. MG is Clinical SubDean in the School of Clinical Medicine and has been Assessment Lead since 2011., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Simulation in surgical training is playing an increasingly important role as postgraduate medical education programs navigate an environment of increasing costs of education, increased attention on patient safety, and new duty hour restrictions. In obstetrics and gynecology, simulation has been used to teach many procedures; however, it lacks a standardized curriculum. Several different simulators exist for teaching various routes and aspects of hysterectomy. This article describes how a formal framework of increasing levels of competencies can be applied to simulation in teaching the procedure of hysterectomy., (Crown Copyright © 2016. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the effects of deployment on basic laparoscopic skills of general surgeons and obstetrics/gynecology (OB/GYN) physicians., Methods: This was a prospective 10-site study. Active duty Army OB/GYN and general surgery physicians scheduled to deploy were invited to participate. Before deployment, they performed fundamentals of laparoscopic surgery (FLS) tasks and specialty-specific procedures on a virtual reality laparoscopic simulator. Upon returning, physicians repeated the same evaluations. Questions about perceived comfort with laparoscopic procedures were asked before and after deployment. Statistical analysis included paired t tests for continuous variables and nonparametric for ordinal data with a p value of <0.05 considered significant., Results: 121 deploying providers were invited to participate; 35 agreed and 29 completed the predeployment skills assessment. After deployment, 15 providers had postassessment evaluation data collected, and their results were used for analysis. Though physicians reported a decrease in their perception of preparedness for advanced laparoscopic procedures and complications, there was no decrement in their performance of FLS tasks or the basic laparoscopic procedures., Conclusion: Time away from regular clinical practice during deployments did not significantly affect surgeons' performance as measured by a virtual reality laparoscopic simulator. Additional study on effects on advanced procedures should be considered., (Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.)

Background: Serious shortage of gynecologists and surgeons for several decades leading to a three-year masters level training was initiated in 2009. However, systematic analysis was not done to assess the graduates' performance. The purpose of this study was to assess improvement in access to emergency surgical and obstetrical care services., Methods: Both quantitative and qualitative methods were employed to assess the competence of emergency surgical officers (ESOs) in their decision making and surgical skills in eight hospitals between 2012 and 2014. Anesthesia time, post-operative hospital stay and change in hemoglobin level were, among others, used as proxy indicators of their surgical skills., Results: A total of 4075 obstetric and surgical operations was performed in the study hospitals. Of which, 93% were done on emergency base. Of the total emergency procedures, 3570(94%) were done by ESOs. Nearly two-thirds (63%) of all the emergency operations were cesarean sections, which were done by ESOs. Out of 239 uterine ruptures, hysterectomy was done for 58%. The proportion of cesarean and instrumental deliveries over the total deliveries were 13% and 0.7%, respectively. Explorative laparotomies and appendectomies were the majority of the non-obstetric emergency operations. Interviewed staff in the respective hospitals stated that ESOs' clinical decision making, surgical skill and commitment to discharge their responsibilities were in the best possible., Conclusions: The study showed that deployment of ESOs made the emergency surgery services accessible to the majority, and their clinical decision making and surgical skills were remarkable.

Objective: To develop and test the validity of an Objective Structured Assessment of Technical Skills (OSATS) tool for breech presentation delivery., Materials and Methods: Monocentric prospective study conducted in the Department of Gynecology, Obstetrics, Fetal Medicine and Reproductive Medicine at the University Hospital of Nice. The study consisted of two parts, the development of the OSATS scoring system and its objective validation. Several experts in obstetrics from university hospital centers and private French hospitals were invited to participate in the development phase of the scoring system. For the validation phase, we formed a group of 20 novices and a group of 20 experts, who had to perform a breech presentation delivery on a simulator, according to a standardized scenario. Each participant was filmed and two experts would then evaluate their performance by viewing anonymized videos and using the OSATS score., Results: The scores obtained by the expert group were significantly higher than those of the novice group, with a total score of 21.73/25 versus 6.95/25 (p < 0.0001), a task-specific score of 87.2/110 versus 44.3/110 (p < 0.0001) and an overall score of 108.93/135 versus 51.25/135 (p < 0.0001), respectively., Conclusion: The OSATS score developed in this study for breech presentation delivery is a reliable model to assess the competence level in procedural skills using a simulator.

Study Objectives: To evaluate the effectiveness of the porcine training model for obstetrics-gynecology (OB/GYN) residents in laparoscopic salpingectomy., Design: Randomized, controlled single-blinded trial., Classification: Canadian Task Force Classification I., Setting: A large community-based teaching hospital., Participants: All postgraduate year 1 through year 4 OB/GYN residents were enrolled (n = 22)., Intervention: All participants underwent a preintervention objective skills assessment test (OSAT), in which the participant performed live human laparoscopic salpingectomy. Residents were randomly assigned (using a computer-generated randomization table, in blocks of 2, stratified by ranked baseline OSAT scores) to the intervention or control group. The intervention group consisted of 1 educational session with presession assigned reading, a 40-min didactic lecture, viewing of a procedural video, and simulation and practice of laparoscopic salpingectomy on a porcine cadaver. The control group received traditional training per routine residency rotations., Measurements and Main Results: Laparoscopic salpingectomy was performed on live patients by study participants pre- and postintervention. These procedures were video recorded, and then scored by a single blinded evaluator of the OSATs. Nine pre- and postintervention OSAT indicators, reflecting provider knowledge and skill, were the primary outcome measures. Secondary outcomes were the changes in 10 subjective measures of comfort, assessed by a pre- and postintervention survey. The outcomes were assessed using 5-point Likert scales (for OSATs 1 = lowest score; for the subjective survey 1 = highest score). The control group OSAT scores did not change (pre: 26.6 ± 10.8, post: 26.2 ± 10.1; p = .65). There were significant improvements in 2-handed surgery (pre: 2.8 ± 1.6, post: 3.5 ± 1.3; p = .004) and use of energy (pre: 2.9 ± 1.3, post: 3.6 ± 1.0; p = .01) in the intervention group, contributing to an overall score change (pre: 26.7 ± 10.6, post: 29.9 ± 9.8; p ≤ .001). The control group had no change in comfort levels. The intervention group experienced both increases (anatomy, steps of surgery, 2-handed surgery, and use of energy) and decreases (reading and learning in operating room) in reported comfort levels., Conclusion: This study demonstrates that simulation can improve surgical technique OSATs. However, of 45 possible points, both groups' average scores were <70% of the optimum. Thus, the improvement, although statistically significant, was relatively small and indicates that further supplementation in training is needed to substantially increase the residents' surgical skills., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

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

The term "hospitalist" refers to physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities may include patient care, teaching, research, and inpatient leadership. The American College of Obstetricians and Gynecologists supports the continued development and study of the obstetric and gynecologic (ob-gyn) hospitalist model as one potential approach to improve patient safety and professional satisfaction across delivery settings. Effective patient handoffs, updates on progress, and clear follow-up instructions between ob-gyn hospitalists and patients, nurses, and other health care providers are vital to maintaining patient safety. Hospitals and other health care organizations should ensure that candidates for positions as ob-gyn hospitalists are drawn from those with documented training and experience appropriate for the management of the acute and potentially emergent clinical circumstances that may be encountered in obstetric care.

Background: A surgeon's skill in the operating room has been shown to correlate with a patient's clinical outcome. The prompt accurate assessment of surgical skill remains a challenge, in part, because expert faculty reviewers are often unavailable. By harnessing the power of large readily available crowds through the Internet, rapid, accurate, and low-cost assessments may be achieved. We hypothesized that assessments provided by crowd workers highly correlate with expert surgeons' assessments., Materials and Methods: A group of 49 surgeons from two hospitals performed two dry-laboratory robotic surgical skill assessment tasks. The performance of these tasks was video recorded and posted online for evaluation using Amazon Mechanical Turk. The surgical tasks in each video were graded by (n=30) varying crowd workers and (n=3) experts using a modified global evaluative assessment of Robotic Skills (GEARS) grading tool, and the mean scores were compared using Cronbach's alpha statistic., Results: GEARS evaluations from the crowd were obtained for each video and task and compared with the GEARS ratings from the expert surgeons. The crowd-based performance scores agreed with the performance assessments by experts with a Cronbach's alpha of 0.84 and 0.92 for the two tasks, respectively., Conclusion: The assessment of surgical skill by crowd workers resulted in a high degree of agreement with the scores provided by expert surgeons in the evaluation of basic robotic surgical dry-laboratory tasks. Crowd responses cost less and were much faster to acquire. This study provides evidence that crowds may provide an adjunctive method for rapidly providing feedback of skills to training and practicing surgeons.

Objectives: To assess the effect of implementation of a newly developed e-learning module on the quality of cervical-length measurements., Methods: With the introduction of cervical-length (CL) measurement in a research setting, a CL measurement e-learning module (CLEM) was developed with the purpose to enhance the knowledge and skills of experienced ultrasonographers. CLEM was designed specifically for ultrasonographers who perform ultrasound in a general obstetrical practice but who do not regularly perform CL measurements. CLEM consists of five theoretical questions and three caliper-placement tests to learn the CL measurement technique. The quality of the CL measurements of CLEM participants was compared with images of non-participants using a CL measurement image score (CIS), defined as the sum of six items which assess the quality of the image. Each CLEM participant submitted five CL images and the images of non-CLEM participants were selected randomly from an ultrasound database., Results: The CIS of the CLEM participants (n = 61) were significantly higher than those of non-CLEM participants (n = 23) (164.9 vs 155.6, respectively; P = 0.03). Visualization of the internal os and positioning of the calipers on the internal and external ora were found to have significantly higher CIS among the CLEM participants than among the non-CLEM participants (P = 0.001 and P < 0.001, respectively)., Conclusions: Introducing CLEM may improve the quality of CL measurements obtained by trained and untrained sonographers., (Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.)

The forces promoting the hospitalist model arose from the need for high-value care; therefore, improving quality and cost has been part of the hospitalist formula for success. The factors driving the rapid growth of generalist and subspecialty hospitalists include nationally mandated quality and safety measures, increasing age and complexity of the hospitalized patient, reduced residency duty hours, increased economic pressures to contain costs and reduce length of stay, and also primary care physicians, and specialists, relinquishing hospital privileges to focus on outpatient practices. Hospitalists are playing key roles in patient safety and quality as either leaders or practitioners in the field., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: There are not enough clinical data from rare critical events to calculate statistics to decide if the management of actual events might be below what could reasonably be expected (i.e. was an outlier)., Objectives: In this project we used simulation to describe the distribution of management times as an approach to decide if the management of a simulated obstetrical crisis scenario could be considered an outlier., Design: Twelve obstetrical teams managed 4 scenarios that were previously developed. Relevant outcome variables were defined by expert consensus. The distribution of the response times from the teams who performed the respective intervention was graphically displayed and median and quartiles calculated using rank order statistics., Results: Only 7 of the 12 teams performed chest compressions during the arrest following the 'cannot intubate/cannot ventilate' scenario. All other outcome measures were performed by at least 11 of the 12 teams. Calculation of medians and quartiles with 95% CI was possible for all outcomes. Confidence intervals, given the small sample size, were large., Conclusion: We demonstrated the use of simulation to calculate quantiles for management times of critical event. This approach could assist in deciding if a given performance could be considered normal and also point to aspects of care that seem to pose particular challenges as evidenced by a large number of teams not performing the expected maneuver. However sufficiently large sample sizes (i.e. from a national data base) will be required to calculate acceptable confidence intervals and to establish actual tolerance limits.

Background: Cumulative sum (CUSUM) analysis has been used for assessing competence of trainees learning new technical skills. One of its disadvantages is the required definition of acceptable and unacceptable success rates. We therefore monitored the development of competence amongst trainees new to obstetric epidural anaesthesia in a large public hospital., Methods: Obstetric epidural data were collected prospectively between January 1996 and December 2011. Success rates for inexperienced trainees were calculated retrospectively for (1) the whole database, (2) for each consecutive attempt and (3) each trainee's individual overall success rate. Acceptable and unacceptable success rates were defined and CUSUM graphs generated for each trainee. Competence was assessed for each trainee and the number of attempts to reach competence recorded., Results: Mean (sd) success rate for all inexperienced trainees was 76.8 (0.1%), range 63-90%. Consecutive attempt success rate produced a learning curve with a mean success rate commencing at 58% on attempt 1. After attempt 10 the attempt number had no effect on subsequent success rates. From these results, the acceptable and unacceptable success rates were set at 65 and 55% respectively. CUSUM graphs demonstrated 76 out of 81 trainees competent after a mean of 46 (22) attempts., Conclusions: CUSUM is useful for assessing trainee epidural competence. Trainees require approximately 50 attempts, as defined by CUSUM, to reach competence., (© The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: clinical reasoning was once thought to be the exclusive domain of medicine - setting it apart from 'non-scientific' occupations like midwifery. Poor assessment, clinical reasoning and decision-making skills are well known contributors to adverse outcomes in maternity care. Midwifery decision-making models share a common deficit: they are insufficiently detailed to guide reasoning processes for midwives in practice. For these reasons we wanted to explore if midwives actively engaged in clinical reasoning processes within their clinical practice and if so to what extent. The study was conducted using post structural, feminist methodology., Question: to what extent do midwives engage in clinical reasoning processes when making decisions in the second stage labour?, Methods: twenty-six practising midwives were interviewed. Feminist interpretive analysis was conducted by two researchers guided by the steps of a model of clinical reasoning process. Six narratives were excluded from analysis because they did not sufficiently address the research question. The midwives narratives were prepared via data reduction. A theoretically informed analysis and interpretation was conducted., Findings: using a feminist, interpretive approach we created a model of midwifery clinical reasoning grounded in the literature and consistent with the data. Thirteen of the 20 participant narratives demonstrate analytical clinical reasoning abilities but only nine completed the process and implemented the decision. Seven midwives used non-analytical decision-making without adequately checking against assessment data., Conclusion: over half of the participants demonstrated the ability to use clinical reasoning skills. Less than half of the midwives demonstrated clinical reasoning as their way of making decisions. The new model of Midwifery Clinical Reasoning includes 'intuition' as a valued way of knowing. Using intuition, however, should not replace clinical reasoning which promotes through decision-making can be made transparent and be consensually validated., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Episiotomy remains a routine procedure at childbirth in many South-East Asian countries but the reasons for this are unknown. The aim of this study was to determine the knowledge of, attitudes towards and experience of episiotomy use among clinicians in Viet Nam., Methods: All obstetricians and midwives who provide delivery care at Hung Vuong Hospital were surveyed about their practice, knowledge and attitudes towards episiotomy use. Data were analysed using frequency tabulations and contingency table analysis., Results: 148 (88%) clinicians completed the questionnaire. Fewer obstetricians (52.2%) than midwives (79.7%) thought the current episiotomy rate of 86% was about right (P < 0.01). Most obstetricians (82.6%) and midwives (98.7%) reported performing episiotomies on nulliparous women over 90% of the time. Among multipara, 24.6% of obstetricians reported performing episiotomy less than 60% of the time compared with only 3 (3.8%) midwives (P < 0.01). Aiming to reduce 3rd-4th degree perineal tears was the most commonly reported reason for performing an episiotomy by both obstetricians (76.8%) and midwives (82.3%), and lack of training in how to minimize tears and keep the perineum intact was the mostly commonly reported obstacle (obstetricians 56.5%, midwives 36.7% P = 0.02) to reducing the episiotomy rate., Conclusion: Although several factors that may impede or facilitate episiotomy practice change were identified by our survey, training and confidence in normal vaginal birth without episiotomy is a priority.

Background: Complications of abortion are one of the leading causes of maternal mortality worldwide, along with hemorrhage, sepsis, and hypertensive diseases of pregnancy. In Afghanistan little data exist on the capacity of the health system to provide post-abortion care (PAC). This paper presents findings from a national emergency obstetric and neonatal care needs assessment related to PAC, with the aim of providing insight into the current situation and recommendations for improvement of PAC services., Methods: A national Emergency Obstetric and Neonatal Care Needs Assessment was conducted from December 2009 through February 2010 at 78 of the 127 facilities designated to provide emergency obstetric and neonatal care services in Afghanistan. Research tools were adapted from the Averting Maternal Death and Disability Program Needs Assessment Toolkit and national midwifery education assessment tools. Descriptive statistics were used to summarize facility characteristics, and linear regression models were used to assess the factors associated with providers' PAC knowledge and skills., Results: The average number of women receiving PAC in the past year in each facility was 244, with no significant difference across facility types. All facilities had at least one staff member who provided PAC services. Overall, 70% of providers reported having been trained in PAC and 68% felt confident in their ability to perform these services. On average, providers were able to identify 66% of the most common complications of unsafe or incomplete abortion and 57% of the steps to take in examining and managing women with these complications. Providers correctly demonstrated an average of 31% of the tasks required for PAC during a simulated procedure. Training was significantly associated with PAC knowledge and skills in multivariate regression models, but other provider and facility characteristics were not., Conclusions: While designated emergency obstetric facilities in Afghanistan generally have most supplies and equipment for PAC, the capacity of healthcare providers to deliver PAC is limited. Therefore, we strongly recommend training all skilled birth attendants in PAC services. In addition, a PAC training package should be integrated into pre-service medical education.

Although most developing countries monitor the proportion of births attended by skilled birth attendants (SBA), they lack information on the availability and performance of emergency obstetric care (EmOC) signal functions by different cadres of health care providers (HCPs). The World Health Organisation signal functions are set of key interventions that targets direct obstetric causes of maternal deaths. Seven signal functions are required for health facilities providing basic EmOC and nine for facilities providing comprehensive EmOC. Our objectives were to describe cadres of HCPs who are considered SBAs in Tanzania, the EmOC signal functions they perform and challenges associated with performance of EmOC signal functions. We conducted a cross-sectional study of HCPs offering maternity care services at eight health facilities in Moshi Urban District in northern Tanzania. A questionnaire and health facility assessment forms were used to collect information from participants and health facilities. A total of 199 HCPs working at eight health facilities in Moshi Urban District met the inclusion criteria. Out of 199, 158 participated, giving a response rate of 79.4 %. Ten cadres of HCPs were identified as conducting deliveries regardless of the level of health facilities. Most of the participants (81 %) considered themselves SBAs, although some were not considered SBAs by the Ministry of Health and Social Welfare (MOHSW). Only two out of the eight facilities provided all of the required EmOC signal functions. While Assistant Medical Officers are expected to perform all the signal functions, only 38 % and 13 % had performed vacuum extraction or caesarean sections respectively. Very few registered and enrolled nurse-midwives had performed removal of retained products (22 %) or assisted vaginal delivery (24 and 11 %). Inadequate equipment and supplies, and lack of knowledge and skills in performing EmOC were two main challenges identified by health care providers in all the level of care. In the district, gaps existed between performance of EmOC signal functions by SBAs as expected by the MOHSW and the actual performance at health facilities. All basic EmOC facilities were not fully functional. Few health care providers performed all the basic EmOC signal functions. Competency-based in-service training of providers in EmOC and provision of enabling environment could improve performance of EmOC signal functions in the district.

Objective: The purpose of this study was to estimate interobserver variability and correct classification of preterm birth into spontaneous and indicated subtypes., Study Design: This was a cross-sectional study in which a trained obstetric nurse, maternal fetal medicine (MFM) fellow, and MFM faculty member independently reviewed discharge summaries and full medical records to classify preterm birth into "spontaneous" and "indicated" subtypes. Consensus classification was obtained with a senior faculty member and was considered the correct classification. Proportions of correct classification by both discharge summary and full medical record review and by level of reviewer were compared with the use of the χ(2) test. Interobserver variability was estimated with the use of Fleiss' kappa., Results: Of 132 preterm births, 58.8% were spontaneous. Interrater agreement for classification of preterm birth subtype based on the full medical record review was substantial (0.79; 95% confidence interval, 0.76-0.80). Interrater agreement was slightly less, based on discharge summary classification alone (Kappa, 0.73; 95% confidence interval, 0.71-0.79) compared with a full medical record review, but this difference was not significant (P = .3). Correct classifications for research nurse, MFM fellow, and MFM faculty member were 85%, 95%, and 93%, respectively, for the full medical records and 85%, 93%, and 92%, respectively, for the discharge summaries alone. There was no significant improvement in correct classification based on full medical record review compared with discharge summary alone for any level of reviewer (P > .6)., Conclusion: There is substantial, but imperfect, agreement between reviewers for classification of preterm birth into spontaneous and indicated subtypes. Incorrect classification may occur 5-15% of the time, even with experienced research personnel. Discharge summaries that are populated with pertinent clinical data may streamline accuracy for research efficiency., (Copyright © 2014. Published by Elsevier Inc.)

The Society of Gynaecologists and Obstetricians of Burkina Faso (SOGOB) conducted a project to reinforce skills in respectful maternity care among its members and health workers at three facilities. The participatory process allowed health workers to self-diagnose quality of care, recognize their own responsibility, propose solutions, and pledge respectful care commitments that were specific for each unit. Key commitments included good reception; humanistic clinical examination; attentive listening and responsiveness to patient needs; privacy, discretion, and confidentiality; availability; and comfort. These commitments can potentially be modified after each evaluation by SOGOB. Poor working conditions were found to negatively impact on quality of care. High staff turnover, frequent technical malfunctions, and inadequate infrastructure were identified as issues that require future focus to ensure improvements in quality of care are sustainable. Programs that aim to improve the maternity experience by linking good practice with humanistic care merit rollout to all healthcare facilities in Burkina Faso., (Copyright © 2014. Published by Elsevier Ireland Ltd.)

Objective: To develop and test the validity of an objective structured assessment of technical skill (OSATS) tool for vertex presentation delivery simulations., Materials and Methods: Monocentric prospective study conducted in the Department of Gynecology, Obstetrics, Fetal Medicine and Reproductive Biology at the University Hospital of Nice. The study consisted of two parts, the development of the scoring system and then its validation. Experts in obstetrics from several academic institutions and private French hospitals were invited to participate in the development phase of the scoring system. For the validation phase, we formed a group of 20 novices and a group of 20 experts, who performed a childbirth simulation according to a standard scenario. Each participant was filmed and then two experts evaluated their performance with the OSATS score by viewing anonymized videos., Results: The scores obtained by the expert group were significantly higher than those of the novice group, whether we compared the total score or each part of the score (task-specific or global) independently. We obtained a p value of 0.03 for the total score, p = 0.036 for the task-specific score, and p < 0.001 for the overall score., Conclusion: The OSATS score developed in this study for vertex presentation delivery is a reliable mean to assess the medical students' competence in procedural skills using a simulator.

Objectives: The aim of this study was to assess the possible mismatch of obstetrical skills between the training offered in Ecuadorian medical schools and the tasks required for compulsory rural service., Setting: Primary care, rural health centres in Southern Ecuador., Participants: A total of 92 recent graduated medical doctors during their compulsory rural year., Primary and Secondary Outcomes Measures: A web-based survey was developed with 21 obstetrical skills. The questionnaire was sent to all rural doctors who work in Loja province, Southern Ecuador, at the Ministry of Health (n=92)., We Measured Two Categories: 'importance of skills in rural practice' with a five-point Likert-type scale (1= strongly disagree; 5= strongly agree); and 'clerkship experience' using a nominal scale divided in five levels: level 1 (not seen, not performed) to level 5 (performed 10 times or more). Spearman's rank correlation coefficient (r) was used to observe associations., Results: A negative correlation was found in the skills: 'episiotomy and repair', 'umbilical vein catheterisation', 'speculum examination', 'evaluation of cervical dilation during active labour', 'neonatal resuscitation' and 'vacuum-assisted vaginal delivery'. For instance 'Episiotomy and repair' is important (strongly agree and agree) to 100% of respondents, but in practice, only 38.9% of rural doctors performed the task three times and 8.3% only once during the internship, similar pattern is seen in the others., Conclusions: In this study we have noted the gap between the medical needs of populations in rural areas and training provided during the clerkship experiences of physicians during their rural service year. It is imperative to ensure that rural doctors are appropriately trained and skilled in the performance of routine obstetrical duties. This will help to decrease perinatal morbidity and mortality in rural Ecuador., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: To determine individual and contextual factors associated with emergency obstetric and neonatal care (EmONC) competency among primary healthcare staff in Mali., Methods: Between November 2011 and April 2012, a competency test was administered to 196 healthcare workers in 65 community health centers in Mali. The test was scored from 0 to 100, and differences among 5 areas of EmONC were assessed. A multilevel linear regression model was used to determine individual and contextual factors associated with score., Results: The mean score was 66.7 (minimum, 15.9; maximum, 97.7). Knowledge was most deficient for postpartum infection and hypertensive complications. Type of health worker, years of experience, number of days absent, and availability of guidelines for management of obstetric complications within the health center were positively associated with test score (P<0.05). Availability of guidelines was associated with higher competency of physicians, health technicians, and obstetric nurses (P<0.001), and seemed to influence the competency of healthcare workers with fewer than 10 years of experience in particular., Conclusion: Guidelines must be developed that will facilitate standardization of the management of postpartum infection and other less common complications for which healthcare workers show low competence. Strategies to increase use of these guidelines will be necessary., (Copyright © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

Objective: To determine the factors associated with obstetric competency and clinical practice among obstetric care providers in referral health centers in Mali., Methods: The present cross-sectional study was conducted between March and May 2012 among 140 obstetric care providers (obstetric nurses, midwives, and physicians) working in referral health centers in Mali. Emergency obstetric care knowledge and skills were evaluated with clinical vignettes developed using national Malian guidelines. The vignettes covered 5 areas of emergency obstetric care, and the results were used to generate a competency score. A backward stepwise random-effects model using a maximum likelihood estimator was applied to evaluate variables independently associated with competency score., Results: Out of 100, the mean±SD score was 57.8±11.2 for obstetric nurses, 66.4±14.7 for midwifes, and 78.6±13.4 for physicians (P<0.001). Three variables were significantly associated with a higher competency score: professional qualification, working in an urban setting, and working in a health center with a smaller number of obstetric care providers., Conclusion: Increasing the in-service training of both rural staff and lower-level healthcare workers working in larger health centers via facility-based maternal death reviews might help to improve clinical practice and maternal health outcomes., (Copyright © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

Objectives: To explore the reliability and validity of a recently developed instrument for assessment of ultrasound operator competence, the Objective Structured Assessment of Ultrasound Skills (OSAUS)., Methods: Three groups of 10 doctors with different levels of ultrasound experience in obstetrics and gynecology were included. The novices had less than 1 month of experience, the intermediate group had 12-60 months of experience and the senior participants were all consultants. Fifteen participants performed transabdominal fetal biometry and the other 15 participants performed systematic transvaginal gynecological ultrasound scans. All scans were video-recorded and assessed by two blinded consultants using the OSAUS scale. The OSAUS scores were compared between the groups using the Kruskal-Wallis test, and pass/fail scores were determined using the contrasting-groups method of standard setting., Results: For the transabdominal fetal biometry examinations, the mean ± SD OSAUS scores of the novices, intermediates and senior participants were 1.5 ± 0.4, 3.3 ± 0.6 and 4.4 ± 0.4, respectively (P = 0.003). For the systematic transvaginal scans, the mean ± SD OSAUS scores of the novices, intermediates and senior participants were 1.8 ± 0.2, 3.1 ± 0.1 and 3.9 ± 0.5, respectively (P = 0.003). Post-hoc comparisons showed significant differences between each of the groups for both types of scans. The pass/fail score was 2.5 for the transvaginal scan and 3.0 for the transabdominal biometry examinations. The inter-rater reliability was 0.89., Conclusions: Ultrasound competence can be assessed in a reliable and valid way using the OSAUS scale. The pass/fail scores may be used to help determine when trainees are qualified for independent practice., (Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.)

Objective: To explore the association between clinical training characteristics and trainees' level of confidence in performing ultrasound scans independently., Methods: A cross-sectional e-survey was distributed to members of the national societies of junior obstetricians/gynecologists in Denmark, Sweden and Norway (n = 973). Multiple linear regression models were used to explore the effect that amount of time spent in specialized ultrasound units and clinical experience had on trainees' confidence in performing ultrasonography independently. Exploratory factor analysis was used to identify factors that contributed to trainees' confidence in performing ultrasonography. Trainees' ultrasound confidence was finally compared with their expected levels of performance., Results: Of the 682 respondents (response rate 70.1%), 621 met the inclusion criteria. Clinical experience and time spent in specialized ultrasound units were predictors of trainees' confidence in performing ultrasonography independently (P < 0.001). Trainees required more than 24 months of clinical experience and 12-24 days of training in specialized ultrasound units in order to feel confident about performing transvaginal and transabdominal ultrasound scans independently. Three factors were related to ultrasound confidence: technical aspects, image perception and integration of scan into patient care. There were significant differences between trainees' level of confidence and their expected levels of performance (P < 0.001)., Conclusions: Clinical experience and time spent in specialized ultrasound units were predictors of trainees' confidence in performing ultrasonography independently. Discrepancies between trainees' confidence and their expected levels of performance raised concerns about the adequacy of current ultrasound training programs., (Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.)

Aim: To determine agreement of cardiac anomalies between maternal fetal medicine (MFM) physicians and pediatric cardiologists (PC) in fetuses with single umbilical artery (SUA)., Methods: A retrospective review of all fetuses with SUA between 1999 and 2008. Subjects were studied by MFM and PC, delivered at our institution, and had confirmation of SUA and cardiac anomaly by antenatal and neonatal PC follow-up. Subjects were divided into four groups: isolated SUA, SUA and isolated cardiac anomaly, SUA and multiple anomalies without heart anomalies, and SUA and multiple malformations including cardiac anomaly., Results: 39,942 cases were studied between 1999 and 2008. In 376 of 39,942 cases (0.94%), SUA was diagnosed. Only 182 (48.4%) met inclusion criteria. Cardiac anomalies were found in 21% (38/182). Agreement between MFM physicians and PC in all groups combined was 94% (171/182) (95% CI [89.2, 96.8]). MFM physicians overdiagnosed cardiac anomalies in 4.4% (8/182). MFM physicians and PC failed to antenatally diagnose cardiac anomaly in the same two cases., Conclusions: Good agreement was noted between MFM physicians and PC in our institution. Studies performed antenatally by MFM physicians and PC are less likely to uncover the entire spectrum of cardiac abnormalities and thus neonatal follow-up is suggested.

Objective: To assess the knowledge and attitudes of Jordanian obstetricians and gynecologists toward human papillomavirus (HPV) infection and its vaccine., Materials and Methods: A self-administered, anonymous questionnaire was distributed to 400 participants attending scientific meetings. The survey focused on three areas: knowledge of HPV infection, vaccine, and attitude toward vaccination of female adolescents., Results: Survey response rate was of 72.3%. The vast majority knew most of the statements related to knowledge of HPV infection, 66% thought that conventional screening Pap test have a sensitivity of > 75%, and only 44% of them knew that there are 13 to 17 HPV types that cause cervical cancer. The majority of the respondents (79%) knew that the vaccine would lead to long lasting immunity and 45% of the respondents thought that the vaccination would eliminate the need for regular Pap test. The majority (78%) indicated that the vaccine should be given to girls before the beginning of sexually active life. Overall, 67.5% of respondents intend to prescribe HPV vaccines and 79.6% of the respondents intend to recommend the vaccine if it is publicly funded., Conclusion: Most of the gynecologists in Jordan have the intention to recommend HPV vaccine, the deficit in their knowledge of HPV infection and vaccine must be corrected to assure acceptability of the vaccine.