Objective: This study was undertaken to describe abortion attitudes in a diverse cohort of pregnant women enrolled in prenatal care.Study design: A cross-sectional interview study of 1082 demographically diverse gravid women enrolled in prenatal care at less than 20 weeks' gestation was performed.Results: Most participants (92%) supported abortion availability. Half (50%) who were willing to consider an abortion would do so only in the First trimester. Among the gravid women willing to consider an abortion in the first or second trimester, 84% would do so after rape/incest or if their life was endangered and 76% would if their fetus had Down syndrome. Gravid women considering abortion were more likely to be white, older, have had a previous abortion, and to express distrust in the health care system. Women who would not consider abortion were more likely to be multiparous, married/living with partner, and to express greater faith and fatalism about their pregnancy outcome.Conclusion: Although most pregnant women enrolled in prenatal care support abortion availability, about half would only consider a first-trimester procedure. These findings underscore the need for early prenatal genetic counseling, screening, and testing. (c) 2005 Elsevier Inc. All rights reserved.

OBJECTIVE:To compare sexual functioning and health-related quality-of-life outcomes of total abdominal hysterectomy (TAH) and supracervical hysterectomy (SCH) among women with symptomatic uterine leiomyomata or abnormal uterine bleeding refractory to hormonal management. METHODS:We randomly assigned 135 women scheduled to undergo abdominal hysterectomy in 4 U.S. clinical centers to either a total or supracervical procedure. The primary outcome was sexual functioning at 2 years, as assessed by the Medical Outcomes Study Sexual Problems Scale. Secondary outcomes included specific aspects of sexual functioning and health-related quality-of-life at 6 months and 2 years. RESULTS:Sexual problems improved dramatically in both randomized groups during the first 6 months and plateaued by 1 year. Health-related quality-of-life scores also improved in both groups. At 2 years, both groups reported few problems with sexual functioning (mean score on the Sexual Problems Scale for SCH group 82, TAH group 80, on a 0-to-100 scale with 100 indicating an absence of problems; difference = +2.95% confidence interval -8 to +11), and there were no significant differences between groups. CONCLUSION:Supracervical and total abdominal hysterectomy result in similar sexual functioning and health-related quality of life during 2 years of follow-up. This information can help guide physicians as they discuss surgical options with their patients.

OBJECTIVE: To evaluate obstetrics and gynecology resident satisfaction with a comprehensive, integrated abortion rotation.METHODS: The University of California, San Francisco obstetrics and gynecology residency program includes a 6-week PGY-3 family planning rotation at an in-hospital clinic where abortions are provided up to 23 weeks of gestation. Residents annually evaluate the educational value of all clinical rotations on a 5-point Likert scale, with 5 indicating '' maximum value,'' and 1 '' no value.'' Using data from 1998-2003, we compared ratings of the family planning rotation with all other PGY-3 rotations. We also surveyed residents 1 to 3 years after graduation to assess the rotation qualitatively and quantitatively.RESULTS: Forty residents completed the abortion training, none opted out of training, and all completed the evaluations. Of all rotations in die third year, the family planning rotation was the highest rated (4.70), was similar in value to a high-volume surgical rotation (4.51, P > .10) and the elective rotation (4.45, P > .05), and surpassed the average score for all inpatient rotations (4.00, P < .001), continuity clinic (4.10, P < .001), and outpatient clinical experiences (4.06, P < .01). According to residency graduates, the family planning rotation was rated 4.8 (where 5 indicates '' far greater value '' than other rotations), and 85% of respondents rated it of '' maximum learning value.''CONCLUSION: Obstetrics and gynecology residents place high value in the University of California, San Francisco PGY-3 family planning rotation during their training and in their first years of practice. (c) 2005 by The American College of Obstetricians and Gynecologists.

PURPOSE:The purpose of this study was to determine how physician experts make decisions for clinical scenarios in ovarian cancer and describe a profile of factors reported to influence treatment decisions.METHODS:A questionnaire was sent to Full Members of the Society of Gynecologic Oncologists regarding surgery and chemotherapy for scenarios of primary and recurrent ovarian cancer.RESULTS:In a scenario of primary presentation, 94% of respondents chose a treatment of tumor resection over chemotherapy. Despite the preference for surgery in a clinical scenario, 50% agreed with a statement that neoadjuvant chemotherapy is equivalent to primary surgery. In a scenario of recurrent disease, a comparable number of respondents chose a treatment of secondary cytoreductive surgery (45%) versus direct retreatment with chemotherapy (49%). Those choosing surgery responded that they believed in extensive surgery to achieve optimal cytoreduction. Most (62%) respondents described themselves as collaborative in treatment planning, yet only 24% reported that patient preference strongly influences their decision making.CONCLUSIONS:Although a plan for primary cytoreduction is favored, in specific scenarios, views were divided for the role of neoadjuvant chemotherapy. For a recurrent disease scenario, support was divided between secondary cytoreductive surgery and direct retreatment with chemotherapy. Further clinical research is necessary to minimize the discordance between physician beliefs and recommendations.

CONTEXTAlthough a quarter of US women undergo elective hysterectomy before menopause, controlled trials that evaluate the benefits and harms are lacking.OBJECTIVETo compare the effect of hysterectomy vs expanded medical treatment on health-related quality of life.DESIGN, SETTING, AND PARTICIPANTSA multicenter, randomized controlled trial (August 1997-December 2000) of 63 premenopausal women, aged 30 to 50 years, with abnormal uterine bleeding for a median of 4 years who were dissatisfied with medical treatments, including medroxyprogesterone acetate. The participants, who were patients at gynecology clinics and affiliated practices of 4 US academic medical centers, were followed up for 2 years.INTERVENTIONSParticipants were randomly assigned to undergo hysterectomy or expanded medical treatment with estrogen and/or progesterone and/or a prostaglandin synthetase inhibitor. The hysterectomy route and medical regimen were determined by the participating gynecologist.MAIN OUTCOME MEASURESThe primary outcome was mental health measured by the Mental Component Summary (MCS) of the 36-Item Short-Form Health Survey (SF-36). Secondary outcomes included physical health measured by the Physical Component Summary (PCS), symptom resolution and satisfaction, body image, and sexual functioning, as well as other aspects of mental health and general health perceptions.RESULTSAt 6 months, women in the hysterectomy group had greater improvement in MCS scores than women in the medicine group (8 vs 2, P =.04). They also had greater improvement in symptom resolution (75 vs 29, P<.001), symptom satisfaction (44 vs 7, P<.001), interference with sex (41 vs 22, P =.003), sexual desire (21 vs 3, P =.01), health distress (33 vs 13, P =.009), sleep problems (13 vs 1, P =.03), overall health (12 vs 2, P =.006), and satisfaction with health (31 vs 14, P =.01). By the end of the study, 17 (53%) of the women in the medicine group had requested and received hysterectomy, and these women reported improvements in quality-of-life outcomes during the 2 years that were similar to those reported by women randomized to the hysterectomy group. Women who continued medical treatment also reported some improvements (P<.001 for within-group change in many outcomes), with the result that most differences between randomized groups at the end of the study were no longer statistically significant in the intention-to-treat analysis.CONCLUSIONSAmong women with abnormal uterine bleeding and dissatisfaction with medroxyprogesterone, hysterectomy was superior to expanded medical treatment for improving health-related quality-of-life after 6 months. With longer follow-up, half the women randomized to medicine elected to undergo hysterectomy, with similar and lasting quality-of-life improvements; those who continued medical treatment also reported some improvements.

Hysterectomy may be overused as treatment for abnormal uterine bleeding due to benign causes in reproductive women. Medical therapies are an alternative, and there is a need for randomized trials comparing the outcomes of these approaches. Women of reproductive age who continued to have bothersome abnormal uterine bleeding after cyclic hormonal treatment with medroxyprogesterone acetate (MPA; 10–20 mg for 10–14 days/month) for 3–5 months were invited to participate in a randomized trial of hysterectomy versus other medical therapies. Participating gynecologists were free to choose the particular surgical (transabdominal or transvaginal) or medical (generally oral contraceptives and/or a prostaglandin synthetase inhibitor) approaches. Outcomes during 2 years of follow-up include quality of life (primary), sexual function, clinical effectiveness and cost. We screened 1557 women to find 413 who began 3–5 months of MPA; 215 completed this treatment, of whom 102 still had bothersome symptoms, and of these 38 consented to be randomized. Another 25 women with bothersome symptoms after a documented history of 3 months of cyclic MPA were also randomized, for a total of 63. The average age of randomized women was 41; 54% were African-American, and they reported uterine bleeding 12 days/month on average, heavy bleeding 6 days/month. Anemia (hematocrit<32) was present in 38% of African-Americans and 15% of Caucasians (p=0.05). Two thirds of the women had fibroids and 80% reported pelvic pain. Obesity was common (45% had a body mass index (BMI)>30), and associated with a longer duration of symptoms (12 vs. 4 years for BMI<25; p=0.02) and a greater prevalence of incontinence (44% vs. 16%; p=0.046). Although recruitment was difficult, we have completed enrollment in a randomized clinical trial comparing surgical and medical treatments for abnormal uterine bleeding.

Objectives To describe women's preferences for prenatal testing outcomes and to explore their association with sociodemographic characteristics and attitudes.Methods We conducted a cross-sectional study of 584 racially/ethnically and socioeconomically diverse pregnant women aged 16 to 47 years recruited from 23 San Francisco Bay Area practices. We assessed preferences for 12 potential prenatal testing outcomes using the time trade-off metric for all outcomes and the standard gamble metric for two outcomes. Preferences were calculated on a scale of 0 (death) to I (perfect health). Participants also completed a sociodemographic and attitude survey.Results Highest preference scores were assigned to outcomes resulting in the birth of a chromosomally normal infant (mean = 0.91-0.93; median = 0.99-1.00). Lower scores were obtained for outcomes involving pregnancy loss (mean = 0.69-0.87; median = 0.76-0.92), which were correlated with attitudes regarding miscarriage, pregnancy termination, and Down syndrome. The lowest scores were assigned to Down syndrome-affected births (mean = 0.67-0.69; median = 0.73-0.75), which also were correlated with attitudes toward Down syndrome. We did not find a statistically significant relationship between participants' preference scores and age.Conclusion Preferences for prenatal testing outcomes vary according to the pregnant women's underlying attitudes about pregnancy loss and Down syndrome, and not according to her age. Current age/risk-based guidelines should account for individual variation in patient preferences. Copyright (C) 2004 John Wiley Sons, Ltd.

The purpose of this cross‐sectional study of 999 socioeconomically and racially/ethnically diverse pregnant women was to explore prenatal genetic testing attitudes and beliefs and the role of external influences. Surveys in English, Spanish, and Chinese included questions regarding the value of testing, pregnancy, and motherhood; the acceptability of Down syndrome in the subject's community; and the role of social and cultural influences in prenatal testing decisions. We analyzed racial/ethnic differences in all attitudinal and external influence variables, controlling for age, relationship status, and socioeconomic status. We found statistically significant racial/ethnic group differences in familiarity with an individual with Down syndrome and in 10 of 12 attitude, belief, and external influence variables, even after controlling for other sociodemographic characteristics. We also observed substantial variation within racial/ethnic groups for each of these measures. Despite the statistically significant group differences observed, R2 values for all multivariate models were modest and response distributions overlapped substantially. Social and familial contexts for prenatal testing decisions differ among racial/ethnic groups even after accounting for age, marital status, and other socioeconomic factors. However, substantial variation within groups and overlap between groups suggest that racial/ethnic differences play a small role in the social and familial context of prenatal genetic testing decisions. © 2002 Wiley‐Liss, Inc.

OBJECTIVE:To determine whether an interactive educational program would improve obstetrics and gynecology residents' knowledge, attitudes, confidence, and skills in caring for depressed patients. METHODS:We recruited 74 residents from eight residency programs to attend the Depression Education Program, which consists of a 1-hour lecture and two 2-hour workshops combining discussion, diagnosis and treatment tools, critique of a videotape, practice with feedback, and audiotape self-assessment. Before and after the program, participants 1) completed a questionnaire measuring knowledge, attitudes, and reported actions taken with a recent depressed patient; 2) received a standardized patient visit; and 3) kept lists of patients they suspected were depressed. Clinic patients completed a depression screening questionnaire. To assess improvement, we used paired t tests, McNemar chi2 tests, and multivariate models adjusting for training site. RESULTS:The education program led to 3-month improvements in participants' reported use of formal diagnostic criteria (38% before, 66% after; P =.004), clinical actions documented for suspected depression (P =.035), and perceived self-efficacy in depression care (P <.001). Perceived preparedness to diagnose depression, treat with medications, and comanage with a mental health practitioner improved (P <.05 for each). Small improvements in clinical behaviors with standardized patients and clinic-based depression detection rates were not statistically significant. CONCLUSION:The Depression Education Program improved residents' knowledge, confidence, and reported clinical actions with depressed patients, but did not improve most objectively assessed outcomes.

The current study examines gender differences in victim and crime characteristics in an effort to determine the extent to which sexual assault is a similar experience for men and for women. Data from a routine structured interview was obtained from medical charts of 842 women and 128 men seen at an urban hospital-based rape treatment center. Demographic characteristics were similar, although males were more like to identify as gay or bisexual, and women were more likely to be of minority ethnicity. Men were more likely to report acute psychiatric symptoms, a history of psychiatric disorder, and a history of psychiatric hospitalization. Women were more likely to experience vaginal or anal penetration, to sustain injuries, and to make a police report. Implications for services for both men and women are discussed.

Objective: To determine how pregnant women of varying ages, races, ethnicities, and socioeconomic backgrounds value procedure-related miscarriage and Down-syndrome-affected birth.Methods: We studied cross-sectionally 534 sociodemographically diverse pregnant women who sought care at obstetric clinics and practices throughout the San Francisco Bay area. Preferences for procedure-related miscarriage and the birth of an infant affected by Down syndrome were assessed using the time trade-off and standard gamble metrics. Because current guidelines assume that procedure-related miscarriage and Down syndrome-affected birth are valued equally, we calculated the difference in preference scores for those two outcomes. We also collected detailed information on demographics, attitudes, and beliefs.Results: On average, procedure-related miscarriage was preferable to Down syndrome-affected birth, as evidenced by positive differences in preference scores for them (time trade-off difference: mean = 0.09, median = 0.06; standard gamble difference: mean = 0.11, median = 0.02; P < .001 for both, one-sample sign test). There was substantial subject-to-subject variation in preferences that correlated strongly with attitudes about miscarriage, Down syndrome, and diagnostic testing.Conclusion: Pregnant women tend to find the prospect of a Down syndrome-affected birth more burdensome than a procedure-related miscarriage, calling into question the equal risk threshold for prenatal diagnosis. Individual preferences for those outcomes varied profoundly. Current guidelines do not appropriately consider individual preferences in lower-risk women, and the process for developing prenatal testing guidelines should be reconsidered to better reflect individual values. (Obstet Gynecol 2000;96:511-16. (C) 2000 by The American College of Obstetricians and Gynecologists.).

Critical appraisal might be the most important skill to acquire in medical school. Despite its importance, this issue has received little attention in obstetrics and gynecology training. This article describes the approach used at San Francisco General Hospital. We teach critical appraisal in several ways. We provide a series of student seminars that foster critical reading of the literature. Topics range from technology assessment to contraception to sexually transmitted diseases. Evidence-based ward rounds complement the experience. During the rotation, each student formally reviews one topic in women's health using the US Preventive Services Task Force rating system. Although we lack a quantitative assessment of this approach, student feedback has been enthusiastic. Critical appraisal skills enable students to continue their medical education after completion of their formal training.

OBJECTIVE:To compare operative delivery rates across regions of the United States from 1987 to 1994 and to evaluate how the rates of severe obstetric lacerations changed during the same period. METHODS:I used diagnosis and procedure data from the National Hospital Discharge Survey and natality data from the National Center for Health Statistics to describe temporal and regional variations in the rates of cesarean, forceps, and vacuum delivery. I described temporal trends in the rates of cervical and severe perineal lacerations during the same period. I performed exploratory analyses of detailed 1990 data to test for regional differences in demographic risk factors that might explain differences in operative delivery rates. RESULTS:Between 1987 and 1994, cesarean delivery rates fell from approximately 25% to less than 22% in all regions except the South. Operative vaginal delivery rates were stable at 10-12% and were consistently lowest in the Northeast (8.2% in 1994) and highest in the South (12.9% in 1994). Vacuum surpassed forceps deliveries in all regions except the South. The rates of cervical and fourth-degree perineal lacerations declined by 57% and 40%, respectively, whereas the rate of third-degree lacerations did not decline. Demographic risk factors for cesarean delivery were no more prevalent in the South than in other regions. Age under 25 years was the only demographic risk factor for forceps delivery that was more prevalent in the South. CONCLUSION:In all but the southern United States, cesarean delivery rates declined and vacuum surpassed forceps delivery. These regional differences are not explained by differences in demographic risk factors.

Objective: To determine if awareness of methods to reduce vertical transmission of human immunodeficiency virus (HIV) is associated with HIV test acceptance and to clarify patients' attitudes toward routine versus elective prenatal HIV testing.Methods: In a cross-sectional study, 247 antenatal patients were surveyed regarding HIV knowledge, self-perceived HIV risk, and willingness to learn a positive test result. This information, along with demographic and risk factor data, was related to HIV test acceptance. Patients also indicated their attitudes toward routine versus elective prenatal testing for HIV and other common prenatal screening tests.Results: Seventy-two percent of antenatal patients accepted HIV testing. Test acceptance was not associated with the presence of risk factors, self-perceived HIV risk, or demographic factors, including race and ethnicity. Test acceptance was associated positively with patients' knowledge of a medical intervention to reduce vertical transmission and their willingness to learn a positive HIV test result. Only 24% of patients knew that the risk of vertical transmission could be reduced using medication. Sixty-nine percent of patients said that prenatal HIV testing should be routine, whereas 27% said that it should be done only after specific written consent. As a group, our patients viewed HIV screening no differently from screening for other infections in pregnancy.Conclusion: Interventions aimed at increasing HIV testing rates among pregnant women should focus on educating patients about vertical transmission reduction and promising new therapies for HIV infection. Proponents of elective testing should re-evaluate the assumption that patients view HIV testing differently from other prenatal tests for which separate written consent is not required. (C) 1998 by The American College of Obstetricians and Gynecologists.

This study was done to determine whether laparoscopy for ectopic pregnancy in the United States is associated with rapid postoperative discharge, defined as 2 days or less, and to estimate how often ambulatory treatment of ectopic pregnancy occurs without subsequent hospital admission. We used the National Hospital Discharge Survey to estimate the frequency of ectopic pregnancy admissions, operations, and length of hospital stays in 1990. We used the National Ambulatory Medical Care Survey to estimate the number, type, and disposition of office visits for ectopic pregnancy in 1990. According to National Hospital Discharge Survey data, tubal pregnancy led to an estimated 57,000 hospital admissions in 1990. Most (70%) of the 26,000 patients treated with laparoscopy were in the hospital 3 days or more, and most (73%) underwent salpingectomy. The number of ambulatory visits for ectopic pregnancy was too low to estimate reliably according to the standards of the National Center for Health Statistics. We found that laparoscopy was used frequently for the treatment of ectopic pregnancy but was not associated with rapid postoperative discharge. Further research is needed to determine whether these findings persist and whether reimbursement incentives, patient preference, or problems with the diffusion of technology are responsible.

OBJECTIVES: Our objectives were to (1) expand and strengthen the women's health curriculum at the University of California, San Francisco, and (2) evaluate the responses of both medical students and faculty to this curriculum.STUDY DESIGN: A written evaluation of the curriculum in women's health was completed by both students and faculty. Variables studied included mean scores of cases, the overall course score, and the preferences of medical students for faculty specialty in teaching the small groups.RESULTS: The overall course evaluation score was 7.81 (range 1 to 10). For those students who had both faculty from internal medicine or family medicine and obstetrics and gynecology, there was a strong preference that obstetrician-gynecologists teach the majority of the cases.CONCLUSIONS: The new case-based curriculum in women's health was enthusiastically received by both medical students and faculty.

BACKGROUND: We evaluated the predictive value of risk factors for repeat cesarean delivery identified in retrospective studies.STUDY DESIGN: We identified 175 consecutive patients who underwent trial of labor (TOL) and compared detailed admission, intrapartum, and postpartum characteristics of those who required repeat cesarean delivery with those who had vaginal births. We calculated relative risks, positive predictive values, and sensitivities for potentially predictive admission characteristics. We also performed multiple logistic regression and classification analyses.RESULTS: Ninety-five percent of eligible patients underwent a TOL, and 85 percent of them delivered vaginally. Patients who had labor induced and patients with high fetal station on admission were significantly more likely to require repeat cesarean section (relative risk [RR]=2.9 and 2.1; 95 percent confidence interval [CI]=1.5 to 5.3, 1.1 to 4.2, respectively), brit even these patients had high rates of vaginal birth (67 percent and 75 percent, respectively). A subgroup of patients who underwent labor induction and had large fetuses (estimated weight 3,800 g or more) had a 75 percent risk of cesarean delivery (RR=2,5, 95 percent CI=0.9 to 7.5). Multivariate models using different combinations of admission characteristics could not correctly identify which patients would require repeat cesarean delivery.CONCLUSIONS: Admission characteristics with statistically significant risk ratios had low predictive values because of the extremely low rate of repeat cesarean delivery in this population. A larger series is needed to study TOL outcomes in patients with large fetuses who are being induced. We conclude that until risk factors with high predictive value for repeat cesarean delivery are identified, all eligible patients should be encouraged to undergo a TOL.

Objectives. To determine the frequency and cost of operations for stress urinary incontinence in the United States.Methods. We reviewed data from the 1988-1992 National Hospital Discharge Surveys and the 1991 California Office of Statewide Health Planning Survey. We determined the frequency and type of surgical procedures performed for stress urinary incontinence and estimated the total direct costs of these operations in the United States.Results. From 1988 to 1992, the total number of operations for stress incontinence increased from 78,000 to over 1 00,000. The rate of operations increased most in women older than 65 years of age. The total direct cost for treatment of stress urinary incontinence in the United States in 1991 was about $0.5 billion.Conclusions. Operations for treatment of stress urinary incontinence are increasing in frequency in the United States. They are both more commonly performed and more costly than have been previously reported.