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Item Pressure and Pain: A Qualitative Pilot Study Describing the Complexity of Unhoused Women’s Experiences with Reproductive Care(Mary Ann Liebert, Inc., 2025-10-08) Woods, Casey C.; Shanks, Anthony L.; Messmore, Niki; Longtin, Krista J.Introduction: While there is extant literature surrounding barriers to reproductive care in the unhoused population—especially regarding access to contraception—little attention has been given to patient perspectives and the quality of care that is received. The unhoused population, which is disproportionately persons of color and low income, has a higher prevalence of psychiatric and physical disabilities. This is a population that has historically been a victim of eugenics and coercive practice. Study Objective: The purpose of the study is to qualitatively understand the experiences of currently unhoused women with pregnancy, birth control, and sterilization, as well as analyze their perspectives in their clinical encounters over their lifetime. Materials and Methods: Participants (n = 10) were recruited from two shelters in a midwestern city. The sample consisted of those assigned female at birth, are currently experiencing homelessness, and have experience with obstetrical and gynecological health care. A semistructured interview was conducted with each participant utilizing a question bank. Audio was recorded, transcribed, and coded for themes. Results: The main themes coded from the interviews were negative birthing and/or sterilization experience, lack of shared decision-making for birth control and/or sterilization, pressure to undergo sterilization and/or go on birth control, the desire for a nonjudgmental provider, and sexual violence experience. Conclusions/Implications: Our data indicate that women experiencing homelessness (WEH) may prefer contraceptive conversations that are trauma-informed and rooted in a shared decision-making model, which in turn may help WEH develop more agency around their reproductive health care. This pilot study also emphasizes the need for more qualitative research to evaluate experiences directly in the population of interest.Item Neonatal outcomes among pregnancies with red cell alloimmunization requiring doppler monitoring without intrauterine transfusion: A retrospective cohort study(Wiley, 2025-08-22) Arkerson, Brittany J.; Aghajani, Faezeh; Modrall, Katherine E.; Salter, Lucy; Stepaniak, Evelyn C.; Shanks, Anthony L.; Mustafa, Hiba J.Introduction: Red cell alloimmunization in pregnancy occurs when a pregnant person develops antibodies against red blood cell antigens that are foreign to her. These antibodies can cross the placenta and cause hemolytic disease in the fetus and newborn (HDFN), which can lead to complications ranging from anemia and hyperbilirubinemia to stillbirth. Historically managed with invasive monitoring via amniocentesis, the approach shifted toward non-invasive Doppler ultrasound of the middle cerebral artery—using a middle cerebral artery peak systolic velocity (MCA PSV) threshold of 1.5 multiples of the median (MoM)—as a sensitive method to detect moderate to severe fetal anemia. However, more data are needed on neonatal outcomes when intrauterine transfusion is not performed. This study aimed to evaluate the characteristics and outcomes of red cell alloimmunized pregnancies requiring MCA PSV Doppler monitoring but not requiring intrauterine transfusion (IUT) and to investigate prenatal associations or predictors among neonates who required postnatal therapy for HDFN. Methods: This was a retrospective cohort study of a single center of level IV maternity and neonatal care units in the United States between January 2018 and December 2023. We included pregnancies with red cell alloimmunization requiring MCA PSV Doppler monitoring for which the fetus or neonate was shown to be at risk either antenatally or postnatally but did not require an IUT procedure. We excluded red cell alloimmunized pregnancies for which no testing was done either antenatally or postnatally to show whether the fetus or neonate was at risk, which required IUT, and which involved multiple gestations. Descriptive statistics were reported for the entire cohort. We then performed a bivariate comparison between two groups: neonates who received postnatal treatment for HDFN and those who did not. Multivariable logistic regression was performed to investigate prenatal associations or predictors among the neonates who required postnatal therapy for HDFN. Results: A total of 40 eligible pregnancies reached critical titers and needed MCA PSV Doppler monitoring, from which 39 neonates were included in the final analysis. A total of 18 (46.2%) of the at-risk neonates were admitted to the NICU. A total of 22 neonates (56.4%) required phototherapy of any kind (bililights and/or biliblanket), 1 neonate (2.6%) required exchange transfusion, and 5 neonates (12.8%) required IVIG. A total of 13 neonates (33.3%) only required phototherapy. No neonates received IVIG or exchange transfusion as isolated therapy. A total of 11 neonates (28.2%) required RBC transfusions to treat anemia. Only two neonates (5.1%) received RBC transfusion(s) as isolated therapy. Neonates requiring postnatal therapy for HDFN had higher rates of NICU admission (66.7% vs. 13.3%, p = 0.002) and longer NICU stays (median days 7, IQR 0, 19.5 vs. 0; p < 0.001). The multivariable logistic regression analysis showed that antibody titer at pregnancy onset was a significant predictor (OR = 16.33, 95% CI: 1.35–197.77, p = 0.03), while earlier MCA Doppler monitoring showed a non-significant trend toward reduced treatment need (OR = 0.095, 95% CI: 0.006–1.498, p = 0.09). Conclusion: This study confirms earlier studies in clinical predictive data for neonatal outcomes in red cell alloimmunization and highlights the importance of structured postnatal monitoring and timely follow-up.Item An Analysis of Obstetrics and Gynecology Medical Student Performance Evaluation Clerkship Narratives: Insights From the PRIME+ Framework(ACGME, 2025-04) Shui, Michelle L.; Armstrong, Weronika; Altendahl, Marie; Shanks, Anthony L.; Sims, Shireen M.; Ratan, Rini B.; Saab, Said S.Background: Despite existing guidelines for writing clerkship summative assessment narratives, their quality, structure, and utility remain variable. Categorizing Medical Student Performance Evaluation (MSPE) narratives using a framework can reveal patterns and gaps in content, offering actionable insights. Objective: This study aimed to (1) categorize MSPE narrative comments using the PRIME+ framework (professionalism, reporting, interpreting, managing, and educating, and areas for improvement [+]), and (2) examine differences in length and content by gender, race, origin of medical school, and final clerkship grade. Methods: Seven hundred twenty applications to our obstetrics and gynecology (OB/GYN) residency program in 2023 were reviewed, focusing on the OB/GYN core clerkship narrative. Narratives were categorized using the PRIME+ framework, and differences in length and content were assessed by gender, race, origin of medical school, and final grade. Differences between groups were evaluated with nonparametric tests. Results: Six hundred fifty-three narratives from 231 medical schools were included. Fifty-one unique grading systems were reported. PRIME+ domains were represented as follows: professionalism (94.8%, 619 of 653), reporter (71.1%, 464 of 653), interpreter (37.5%, 245 of 653), manager (69.1%, 451 of 653), educator (69.7%, 455 of 653), and areas for improvement (3.7%, 24 of 653). For each domain, <13% of narratives included ≥1 specific example. Median word count differed between US-based (155 words; 95% CI, 148-162) and international (61 words; 95% CI, 51-75) applicants (P=.001). Students earning “honors” had longer narratives (median words 149; 95% CI, 131-164 vs 117; 95% CI, 97-134; P=.001) with more specific examples (1.2 examples; 95% CI, 0.97-1.4 vs 0.88; 95% CI, 0.53-1.2; P=.024) and advanced PRIME+ domains, specifically educator (P=.016). The number of specific examples differed by race (P=.02) but not gender. Conclusions: MSPE narratives for the OB/GYN clerkship demonstrate variability in content and length.Item Impact of the Dobbs Decision on Obstetrics and Gynecology Residency Applications – an Exploratory Survey(The European Society of Medicine, 2025-04-30) Conklin, Alissa M.; Rone, Victoria; Arrocha, Diana; Scott, Nicole P.; Peipert, Jeffrey F.; Shanks, Anthony L.Objective: To evaluate the early impact of the Dobbs v. Jackson Women’s Health Organization decision on Obstetrics and Gynecology (OBGYN) residency applications by analyzing changes in applicant behavior, including application numbers and signal allocation, based on abortion law categories, program prestige, geographic region, and the availability of family planning fellowships. Study Design: This cross-sectional survey assessed 61 medium-to-large OBGYN residency programs to examine application trends before and after the Dobbs decision. Data were collected on residency applications for the 2021–2022 and 2022–2023 application cycles, the number of gold and silver signals received in the 2022 Electronic Residency Application Service (ERAS) cycle, program prestige (US News & World Report and Doximity rankings), geographic region (Center for Disease Control and Prevention (CDC)-defined), and the presence of a family planning fellowship or Ryan Program affiliation. Descriptive statistics, paired t-tests, and analysis of variance (ANOVA) were used to analyze differences in application numbers and signal allocation. Results: Across all abortion law categories, applications declined from the 2021–2022 to the 2022–2023 cycle (mean: 895.9 vs. 856.7, p = 0.02), with the largest decrease in states with abortion restrictions (-7.58%). Programs in states with abortion protections received significantly more gold (p = 0.04) and silver signals (p < 0.001) than those in restrictive states. Programs offering family planning fellowships and those affiliated with the Ryan Program also received more signals (p < 0.05). Conclusion: Programs in abortion-restrictive states received fewer applications and signals, suggesting applicants prioritize abortion training access. These trends may impact the geographic distribution of OBGYNs and reproductive healthcare availability. Implications: Declining applications to restrictive states may exacerbate maternity care shortages. Further research is needed to assess long-term effects on workforce retention and training.Item Integration of In Vitro Binding Mechanism Into the Semiphysiologically Based Pharmacokinetic Interaction Model Between Ketoconazole and Midazolam(Wiley, 2013-09-11) Quinney, Sara K.; Knopp, Shawn; Chang, Chien; Hall, Stephen D.; Li, Lang; Obstetrics and Gynecology, School of MedicineIn vitro screening for drug-drug interactions is an integral component of drug development, with larger emphasis now placed on the use of in vitro parameters to predict clinical inhibition. However, large variability exists in Ki reported for ketoconazole with midazolam, a model inhibitor-substrate pair for CYP3A. We reviewed the literature and extracted Ki for ketoconazole as measured by the inhibition of hydroxymidazolam formation in human liver microsomes. The superset of data collected was analyzed for the impact of microsomal binding, using Langmuir and phase equilibrium binding models, and fitted to various inhibition models: competitive, noncompetitive, and mixed. A mixed inhibition model with binding corrected by an independent binding model was best able to fit the data (Kic = 19.2 nmol/l and Kin = 39.8 nmol/l) and to predict clinical effect of ketoconazole on midazolam area under the concentration-time curve. The variability of reported Ki may partially be explained by microsomal binding and choice of inhibition model.Item "I'm supposed to be a helper": Spiritual distress of abortion providers after the Dobbs decision(Elsevier, 2025-02-22) Bode, Leah M.; Kumar, Komal A.; McQuillan, Josie C.; Scott, Nicole P.; Bernard, Caitlin; Obstetrics and Gynecology, School of MedicineBackground: The Dobbs v. Jackson Women's Health Organization decision has undoubtably affected the practice of abortion providers nationally. We hypothesized that Dobbs has also impacted the ways in which providers experience meaning and purpose through their work, which are elements of spirituality. Objective: We sought to describe the spectrum of spirituality of abortion providers and understand whether and how the Dobbs decision caused spiritual distress. Study design: For this qualitative study, we conducted video interviews with 26 abortion providers from 17 states between November 2022 and February 2023. States were classified according to the Guttmacher Institute classifications from most restrictive to very protective as of December 2022. Interviews included questions such as, "Can you describe your own sense of spirituality or spiritual identity?" and "How does your spiritual belief inform your response to the Dobbs decision?" Results: Participants' states of practice were well-distributed across the abortion restrictive-protective spectrum. The majority of participants were spiritual, while less than half identified as part of an organized religion. Many participants felt a spiritual call or obligation to provide abortion care and 46% described abortion as a spiritual act for provider and/or patient. Most participants experienced spiritual distress (74%), including those practicing in states across the restrictive-protective spectrum. Of note, 92% of participants described their spirituality as helpful in coping with the effects of the fall of Roe v. Wade. Sources of strength included advocacy, agency, legislative work, and community; over half specifically cited the abortion provider community. Conclusions: The Dobbs decision-and subsequent state-level abortion restrictions-impacts abortion providers by causing spiritual distress. While many abortion-restrictive laws are influenced by religious or spiritual beliefs, it is important to recognize that abortion providers are also spiritual individuals.Item Dietary Inflammatory Index Is Differentially Associated With Cardiometabolic Health After Pregnancy on the Basis of Adverse Pregnancy Outcome Exposure(American Heart Association, 2024) Jancsura, McKenzie K.; Wirth, Michael D.; Helsabeck, Nathan P.; Mercer, Brian M.; Haas, David M.; Greenland, Philip; McNeil, Rebecca; Levine, Lisa D.; Silver, Robert M.; Yee, Lynn M.; Saade, George R.; Khan, Sadiya S.; Chung, Judith H.; Grobman, William A.; Obstetrics and Gynecology, School of MedicineBackground: Inflammatory diets may influence risk of cardiovascular disease. Subsequent cardiovascular disease is also influenced by adverse pregnancy outcomes (APOs) such as preterm birth, small-for-gestational-age birth, gestational diabetes, and hypertensive disorders of pregnancy. However, the associations between inflammatory diet, APOs, and cardiometabolic health remain unclear. Methods and results: We used data from the nuMoM2b (Nulliparous Pregnancy Outcomes Study Monitoring Mothers-to-Be) HHS (Heart Health Study) to assess the relationship between dietary quality and cardiometabolic health. We calculated Energy-Adjusted Dietary Inflammatory Index scores representing the inflammatory burden in a person's diet. We used linear regression to determine the association between Energy-Adjusted Dietary Inflammatory Index score and cardiometabolic outcomes. We performed stratified analyses for outcomes with a significant interaction between Energy-Adjusted Dietary Inflammatory Index and APO. Data were available from 3249 participants at a median of 3.1 years after delivery. Higher Energy-Adjusted Dietary Inflammatory Index scores were associated with higher body mass index (B=0.29 kg/m2 [95% CI, 0.16-0.42]), waist circumference (0.66 cm [95% CI, 0.39-0.93]), diastolic blood pressure (0.26 mm Hg [95% CI, 0.09-0.44]), mean arterial pressure (0.23 mm Hg [95% CI, 0.06-0.40]), triglycerides (2.11 mg/dL [95% CI, 1.05-3.18]), creatinine (2.78 mg/dL [95% CI, 1.13-4.44]), insulin (exp[B]=1.04 [95% CI, 1.03-1.05]) and C-reactive protein (exp[B]=1.07 [95% CI, 1.04-1.10]), and lower high-density lipoprotein cholesterol (-0.41 mg/dL [95% CI, -0.66 to -0.37]) (all P<0.01). Significant interactions with APO (P<0.05) were identified for body mass index and waist circumference, with stratified analysis revealing stronger associations for individuals with APOs. Conclusions: A more proinflammatory diet was associated with worse cardiometabolic health measures, and these relationships differed by a person's APO history. Further investigation should establish how dietary modifications after pregnancy may potentially mitigate cardiovascular disease risk.Item Maternal Preconception Omega-6, Omega-3, and Omega-6:Omega-3 Intake and Uterine Artery Indices in Mid-Gestation(Thieme, 2025) Finch, Amara; Joss-Moore, Lisa; Allshouse, Amanda A.; Blue, Nathan; Haas, David M.; Grobman, William; Parry, Samuel; Saade, George; Silver, Robert M.; Obstetrics and Gynecology, School of MedicineObjective: Maternal preconception diet influences pregnancy health and fetal outcomes. We examined the relationship between preconception fatty acid (FA) intake and uterine artery indices in mid-gestation in a large, heterogeneous cohort of nulliparous individuals. Study design: This is a secondary analysis of the nuMom2b (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be) study. Dietary ω-6 and ω-3 FA intake was assessed with food frequency questionnaires and uterine artery indices were obtained via Doppler studies in the second trimester. For our primary outcome of pulsatility index (PI) > 1.6, we compared proportions by each dichotomous FA exposure and tested differences with chi-square test. Results: For PI > 1.6, odds ratio for the unfavorable FA quartile compared with remaining quartiles for the exposures were 0.96 to 1.25, p = 0.157 (ω-6 FA); 0.97 to 1.26, p = 0.124 (ω-3 FA); 0.87 to 1.14, p = 1.00 (ω-6:ω-3 FA ratio). Conclusion: No significant associations between self-reported maternal preconception ω-6 and ω-3 FA intake and uterine artery Doppler indices measured during the second trimester were observed.Item Perceived benefits and barriers to the use of long-acting injectable antiretroviral treatment among adolescents and young people living with HIV in Western Kenya: qualitative findings from the KuwaFree! LiveFree! Study(Frontiers Media, 2025-03-07) Hassan, Shukri A.; Munyoro, Dennis; Maju, Mehar; Biegon, Whitney; Bakari, Salim; Kaguiri, Eunice; Jumah, Anjellah; Omollo, Mark; Obare, Valerie; Bernard, Caitlin; Apondi, Edith; Were, Edwin; Patel, Rena C.; Obstetrics and Gynecology, School of MedicineIntroduction: Adolescents and young people living with HIV (AYPLHIV) face significant hurdles in adhering to daily oral antiretroviral therapy (ART). Long-acting (LA) ART, such as injectable cabotegravir and rilpivirine, may help overcome these hurdles. However, little is known about the perceived benefits and barriers to LA ART usage by AYPLHIV in resource-limited settings. Methods: We conducted focus group discussions (FGDs) with four target groups of adolescents/youth, providers, policymakers, and other advocates in western Kenya from November 2021 to April 2022. The FGDs elicited participants' thoughts on LA ART implementation in Kenya, particularly the benefits and barriers of LA ART use amongst AYPLHIV. Our analysis combined both inductive and deductive approaches, beginning with open coding of the data, then organizing them in predetermined socio-ecological model (SEM) domains. Results and discussion: We conducted a total of seven FGDs with 58 participants across four stakeholder groups: AYPLHIV (2 FGDs, n = 14), healthcare providers (2 FGDs, n = 19), health/youth advocates (2 FGDs, n = 16), and policymakers (1 FGD, n = 9). We identified several benefits, largely centered around the individual and interpersonal level, as well as barriers, largely centered around the health systems levels. Participants viewed LA ART as a welcome alternative to oral ART due to benefits like improved adherence, reduced pill burden, increased convenience, enhanced privacy, decreased stigma, lower risk of accidental disclosure, and convergence in using LA contraception. At the interpersonal level, LA ART was valued for furthering relationships, especially for AYPLHIV (e.g., dating). At the health systems level, LA ART expanded first-line treatment options. Conversely, barriers to health systems integration included conflicts with service models, increased clinic burden, supply chain issues, and waste disposal. Individual-level barriers included fears of injections, side effects, concerns about a new drug, and reduced effectiveness if mixing LA ART with oral ART. Conclusions: The perceived benefits of LA ART for AYPLHIV, centering on individual and interpersonal levels of positive impacts, appear in tension with the anticipated barriers for health systems readiness in Kenya. While the prospect of offering LA ART is overwhelming positive, country programs will have to invest in health systems readiness before rolling out LA ART.Item Facilitating Global Collaborations for Pregnancy and Pediatric Biomarker Research Through a Biobank Database: The COPPER Project(Elsevier, 2024) Faysal, Hani; Quinney, Sara K.; Haas, David M.; Obstetrics and Gynecology, School of Medicine