Ryan Program provides comprehensive familyplanning training.
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Multiple projects contribute to improved patient safety, pregnancy outcomes, and childbirth experience.
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Midwife seeks to decode nonverbal labor language during physiologic childbirth.
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Research operations manager joins department to assist investigators throughout their projects.
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Advanced practice providers (APPs) play an indispensable role in maternity care. Among them are certified nurse midwives, who set Dartmouth Health apart from many other institutions. “Not enough programs in the U.S. have midwives as an option for maternity care,” says Ilana Cass, MD, chair of the Department of Obstetrics and Gynecology. “But it’s in our DNA.”
Cass is proud of the department’s research activities, particularly those led by midwives. One is conducting research on interpreting nonverbal labor cues as she pursues a Doctor of Midwifery degree, and another has secured grants to support several projects. A research operations manager recently joined the department to assist faculty and resident investigators with the initial legwork of starting their research projects.
In recognition of Dartmouth Health’s exceptional care, Newsweek named Dartmouth Hitchcock Medical Center among America’s Best Maternity Hospitals in 2022, and U.S. News & World Report rated it as high-performing in maternity care as well as in ovarian cancer surgery and uterine cancer surgery in 2022-2023.
The department’s research activities will benefit not only Dartmouth Health patients and providers, Cass says, but also the broader field of obstetrics and gynecology.
I am proud to share the second annual newsletter highlighting exciting developments in the Department of Obstetrics and Gynecology. This year I want to spotlight progress we have made in expanding our academic footprint as well as our coordinated departmental efforts to deliver outstanding clinical care. The department earned national recognition from U.S. News & World Report as a top performer in maternity care in 2022 as well as in ovarian and uterine cancer surgery. These designations speak to the expertise and ongoing commitment of our teams to provide the highest-quality care to the patients of our region.
At a time when many healthcare resources and services in northern New England are reduced, Dartmouth Health has been recognized as a clear leader in providing safe, innovative, patient-centered OB/GYN care.
Our growing research infrastructure has expanded opportunities for our faculty and our learners. Daisy Goodman, DNP, MPH’14, CARN-AP, APRN, CNM, has garnered research grants to better screen our most marginalized obstetrics patients and to deploy resources to optimize their care. The midwife division has embarked on innovative research to better understand and improve the physiologic birth experience through a project on the language of labor led by Jessica Densmore, CNM. Additionally, in a joint project, Anna Childs, CNM, joins Julie Braga RES’09, and Claire Grzymala, MD, in improving familycentered cesarean births. Our monthly departmentwide research roundtables, led by Daisy, have played a critical role in fostering a research community to share expertise and feedback on projects at all stages of development. This year’s Resident Research Day was a testament to the depth and breadth of our research endeavors: The event featured our chief residents’ projects as well as the research work of our first graduating Female Pelvic Medicine and Reconstructive Surgery fellow, Kristen Gerjevic RES’17, FEL’22.
This year required that we reaffirm our strong commitment to reproductive justice for all. In the face of the first abortion ban in New Hampshire’s history, at 24 weeks, and the U.S. Supreme Court’s Dobbs v. Jackson Women’s Health Organization decision that overturned Roe v. Wade, we responded with advocacy by providing expert testimonial in the state capital, and expanded relationships with other state organizations to secure patients’ access to the
full scope of reproductive care. We have partnered with Planned Parenthood of Northern New England, the Reproductive Freedom Fund of New Hampshire, and the New Hampshire Women’s Foundation to raise one voice in support of reproductive rights. Our department offers the only OB/GYN training program in New Hampshire, and our commitment to providing our learners comprehensive training in family planning is reflected in our distinction as a Ryan Residency Program, under the leadership of Amy Paris, MD, MS. The department has redoubled its efforts to improve access, financial assistance, and counseling for all patients through important collaborations within Dartmouth Health, including the departments of Radiology, Anesthesiology, and Community and Family Practice, that reflect our shared mission to patient care.
I’m pleased to welcome our first social worker, Beatrice Ngugi, MSW, who will serve patients and families in our ambulatory space. She is a groundbreaking addition to our department, as she will enhance the patient experience in so many ways.
We are delighted to update you on our progress in the departmental mission of achieving clinical, scholarly, and educational excellence and to share the national recognition we have earned for these efforts. I look forward to providing future updates regarding our ongoing department activities and achievements. Thank you for your continued support on this journey.
Ilana Cass, MD Chair, Obstetrics and Gynecology and Vice President Service Line, Dartmouth Hitchcock Medical Center Professor, Obstetrics and Gynecology, Geisel School of Medicinedartmouth-hitchcock.org/obgyn
While all accredited obstetrics and gynecology residency programs are required to provide training in family planning, the Kenneth J. Ryan Residency Training Program in Abortion and Family Planning is a designation of excellence in this education.
For nearly 10 years, the Department of Obstetrics and Gynecology’s Ryan Program has elevated residents’ training for first- and second-trimester abortion care beyond the standard requirements of the Accreditation Council for Graduate Medical Education (ACGME). This exceptional training sets Dartmouth Health (DH) apart: Only 34% of OB/GYN residency programs across the country have implemented the Ryan Program. Residents with moral or religious objections to induced pregnancy termination can opt out of abortion training while still learning other important clinical family-planning skills.
“Some institutions have abortion training in one rotation as a normal part of a resident’s training in family planning,” says Amy Paris, MD, MS, the director of Family Planning. “The requirement for the Ryan Program is to have rotations to meet a minimum number of abortion care cases, as well as miscarriage and complex contraception care.”
The Ryan Program residents integrate evidence-based and patient-centered practices, such as first-trimester medication and office-based manual vacuum aspiration, and second-trimester dilation and evacuation. As with other clinical competencies, residents first learn by watching an attending perform the procedure. Then the resident assists, and later performs the abortion, all with increasing independence. The Ryan Program has been shown to improve residents’ competence in family-planning care, even for partially participating residents who opt out of abortion training.
Paris emphasizes that resident competence in abortion care will be more difficult to achieve in certain states since the U.S. Supreme Court’s ruling to overturn Roe v. Wade, the 1973 decision that women have a constitutional right to an abortion.
“The ruling makes it hard for residents where abortion is banned to become proficient in performing abor-
tions,” Paris says, and adds that they will also be limited in the breadth of counseling they can give pregnant patients regarding available options in such states. “New Hampshire has few restrictions on abortion, and we’re able to train our residents very well. But nearly half of OB/GYN residents are in or expected to be in states that ban abortions, and that’s going to be a problem.”
In states where abortion is illegal, physicians still treat situations of miscarriage and fetal demise— competencies that are part of family-planning training. Paris notes that in states with abortion bans, there will be fewer uterine evacuations for residents to learn from, making it harder to complete their experience. Therefore, if residents cannot legally be trained in a certain state, the ACGME requires that they must have an out-of-state rotation to learn these family-planning skills—a costly challenge for residencies in those states.
The department at DH remains dedicated to the entire spectrum of reproductive justice.
“Reproductive justice is the human right to maintain bodily autonomy,” Paris says. “The idea isn’t just about abortion; it’s about deciding whether and when to have children. It’s also about having healthy families, healthcare, nutrition, and safe communities. Reproductive justice looks at the big picture.”
Leading and supporting clinical research initiatives has become a critical aspect of improving patient care in the Department of Obstetrics and Gynecology.
As part of those research activities, Daisy Goodman, DNP, MPH’14, CARN-AP, CNM, vice chair of research for OB/GYN and director of integrated women’s health services at Dartmouth Health’s perinatal addiction treatment program, serves as the co-principal investigator for a research study called Moms in Recovery (MORE): Defining Optimal Care for Pregnant Women and Infants. The study compares models of delivery for medication for opioid use disorder (MOUD) for pregnant people to learn whether integrating prenatal and addiction care—rather than patients seeing a specialty provider for MOUD and a different provider for prenatal care—improves outcomes of pregnancy.
Another of Goodman’s projects is investigating how to improve access to telehealth to effectively overcome barriers to healthcare and improve outcomes for pregnant people with substance use disorders. The study focuses on people living in rural areas with limited access to maternity care and behavioral health services due to geographic distance or economic circumstances.
In collaboration with colleagues at The Dartmouth Institute and Dartmouth Hitchcock Population Health, Goodman is also studying the department’s implementation of a social determinants of health questionnaire to screen patients at their first prenatal appointment, at 28 weeks’ gestation, and postpartum. This questionnaire is accessible to patients through the secure portal, on a tablet at the office visit, or through a medical interpreter if language interpretation services
are needed. When a patient screens positive, the results are sent to one of two teams, depending on the patient’s needs. A community health worker team responds to nonmedical needs, such as transportation, housing, or food security. For patients with more complex or clinical needs, such as partner violence, legal issues impacting health, or mental health assessment, the person is referred to a social worker.
“The screener allows us to better understand how social determinants of health affect clinical outcomes so we can care for the whole person,” Goodman says. “This has a direct benefit for patients in terms of facilitating access to urgently needed resources. For example, about 10% of our patients are screening positive for food insecurity, and we can connect them with supplemental food programs and other critical resources they need.”
Another Dartmouth Health group is conducting research on improving scheduled cesarean birth experiences. Anna Childs, MSN, CNM, is working alongside Julie Braga RES’09, and resident Claire Grzymala PGY-2, on a project to develop researchsupported standards for family-centered cesarean births, particularly for patients who had planned to have a physiologic birth, which uses minimal medical intervention during labor and delivery. Childs conducted grand rounds on the literature, and Grzymala has developed the study, Patient Preferences at Cesarean, into a quality improvement (QI) project.
Sometimes a patient who wants to have a physiologic birth has a single complication, such as the baby being breech, that makes a vaginal birth a less optimal mode of delivery. “When someone is expecting to have an unmedicated birth and they’re told that they need a scheduled cesarean section for safety, that’s really hard on them,” says Childs, a midwife who has scrubbed for cesarean births. Options such as a clear drape and immediate skin-to-skin contact can help improve the cesarean experience and reduce postpartum mood disorders. Family-centered options, such as a support person being in the operating room when the patient receives the epidural, also help reduce anxiety for both patient and partner.
Among its methods, the QI project uses a questionnaire for patients to complete before the scheduled cesarean, so they can consider their wishes and expectations ahead of time. Using this information, the entire medical team can help implement the
patient’s desires and improve the birth experience. With supporting research data, Childs, Braga, and Grzymala anticipate this questionnaire can become a resource for clinicians in the future.
“We’re finding ways to make the birth feel like birth and not like surgery,” says Childs, who credits the dedication of all the staff in the department with creating a holistic approach to surgical birth. “Because it’s not just surgery—you’re becoming a parent. Midwives and OB/GYNs are collaborating to find ways to combine clinically safe surgery with the magical mystery of birth.”
Midwives and OB/GYNs are collaborating to find ways to combine clinically safe surgery with the magical mystery of birth.”
Anna Childs, MSN, CNMGoodman, who holds a Doctor in Nursing Practice (DNP) degree, has garnered funding for her research through grants from the Patient-Centered Outcomes Research Institute (PCORI), the U.S. Health Resource and Service Administration (HRSA) and Point32Health. She notes that doctorally prepared nurses can apply for federal funding as a principal investigator, and they can participate deeply in implementation and research. She is excited that a remote, part-time DNP program was recently started at Colby-Sawyer College in New London, New Hampshire. A PhD in Nursing is also a new option for doctoral preparation for nurses with advanced degrees. Goodman hopes the new programs will encourage more of her colleagues to pursue terminal degrees, and she is particularly enthusiastic about the DNP option.
“The DNP is designed to provide doctorate-level education for someone who is not leaving clinical practice,” Goodman says. “PhD candidates usually step away from the clinical program for their studies and often don’t come back. But the DNP keeps people in clinical care while doing their training, and then later they can think about doing clinical research. This benefits patients because the goal of the DNP is for someone to implement what we know are best practices and then evaluate whether outcomes are what we hoped they would be. It’s the perfect degree to have maximum effect for improving patient care.”
Obstetrics and gynecology residents and fellows participate in scholarly activity as part of their training at Dartmouth Health, and in May 2022, five learners presented their research and findings at Resident Research Day.
At the event, Kimberly D. Gregory, MD, MPH, gave her keynote address on “Research—From idea to implementation: Case study of the development and implementation of the Childbirth Experience Survey (CBEX).” Gregory is the vice chair of Women’s Healthcare Quality and Performance Improvement and the Helping Hand Chair in Maternal-Fetal Medicine at Cedars Sinai Medical Center. She is also on the faculty at the David Geffen School of Medicine at University of California, Los Angeles and the UCLA Fielding School of Public Health.
Alena Tofte MPH’15,
PGY-4Tofte reviewed nearly 100,000 obstetrics transfers and found that patients who had federally subsidized insurance or no insurance were more likely to be transferred than patients with private insurance.
Kimberly D. Gregory, MD, MPH
“Kimberly Gregory is an influential and accomplished figure in our field, so it was a privilege and an honor to have her speak at Resident Research Day,” says Amy Paris, MD, MS, the director of Family Planning. “The residents and faculty were inspired by her talk on patientcentered outcomes in obstetrics. This helps our residents understand where they could go professionally with their research if they choose to. It was an energizing experience for them.”
Among the projects, the residents and one fellow investigated the correlation between patients’ medical insurance and their access to care and health outcomes, predictors of vulvar cancer, whether testosterone therapy in transgender patients increases the risk of endometrial cancer prior to gender-affirming surgery, disparities in access to telehealth, and variation of treatment of vaginal prolapse across the country. Lindsay Drew PGY-4 won this year’s award for best research project.
dartmouth-hitchcock.org/obgyn
“While this relationship doesn’t prove causality because there are other variables, Alena looked at these transfers through an equity lens to find the predictors of who is at high risk of bad outcomes during childbirth,” Paris says.
Jill Roberts PGY-4Roberts discovered a novel association between the GATA binding protein 3 (GATA3) and the progression to vulvar cancer or recurrent differentiated vulvar intraepithelial neoplasia (dVIN).
“Jill found that GATA3 staining may be useful in diagnosing dVIN, and this
could help determine whether patients are at lower or higher risk for cancer and how aggressively a doctor decides to treat them,” Paris says.
Maris Toland PGY-4
Uterine and Ovarian Histopathological Findings Following Administration of Exogenous Testosterone for Gender Affirmation: A Systematic Review
Toland conducted a literature review to discover whether patients receiving testosterone for gender-affirmation therapy had a low incidence of endometrial cancer.
“Maris adds to the body of knowledge that patients seeking a hysterectomy after receiving testosterone don’t need a biopsy without having clinical symptoms of cancer. This can help prevent a potentially traumatic office visit,” Paris says.
Drew looked at the sociodemographics of patients seen via telehealth during the pandemic and found certain factors, such as age and insurance status, were associated with whether patients completed telehealth visits.
“Telehealth is a new modality for us, so it’s important for us to figure out the disparities and how we can make healthcare more equitable for all our patients,” Paris says.
Gerjevic investigated the variation of care in different hospital referral regions across the U.S. regarding the treatment of vaginal prolapse. She found significant geographic disparities among female Medicare beneficiaries.
“It raises the issue of potential inequities in how we offer care to patients,” says Kris Strohbehn, MD, FACOG, FACS, Gerjevic’s fellowship director. “This research will open more studies to determine why there’s variation in care.”
People experiencing physiologic labor—meaning labor with minimal medical intervention, such as an epidural—communicate with their healthcare support team in a nonverbal “labor language,” but very little research has been published on this language. Jessica Densmore, MSN, CNM, a certified nurse midwife at Dartmouth Health, aims to make a contribution to the literature.
“The nonverbal labor language includes body movements, sounds, not necessarily words, and other labor cues that people who are experiencing physiologic birth use to communicate the intense sensations they’re feeling and to help them through those sensations,” says Densmore, who is completing her Doctorate in Midwifery from Thomas Jefferson University in Philadelphia.
For her research, Densmore is surveying and interviewing people who have experienced physiologic birth to learn how they expressed their labor sensations and the responses they received, both positive and negative, from their healthcare team. She is documenting which of those responses were helpful during the labor experience and which were not.
“When I’m in a labor room, I work really hard to minimize distractions during contractions,” Densmore says. “I sit off to the side, lower than the person I’m taking care of so that I’m not a towering presence. I treat that room as their home space and try to be respectful of their needs for privacy in that space.
“People who are coping well in the labor experience tend to have a rhythm to how they move their body and the sounds they make,” she adds. “I observe those rhythms and make sure they don’t need to do anything differently, like get in the bath or shower, or stand up or lie down. I’m watching for what they need based on the cues they’re giving me.”
Densmore hopes her research will lay a foundation for codifying labor language in the future, with the goal of teaching new providers entering maternity care to better interpret that language and understand how they can best support the person in labor.
The Department of Obstetrics and Gynecology has a new research structure to help investigators get their projects up and running smoothly—and Morgan Mazanec MPH’21, is at their service.
“Getting started with research projects and submitting grants can be really daunting, and investigators don’t have to do it alone,” says Mazanec, the department’s research operations manager, a position she started in August 2022. “I can help make sure their studies are following the right requirements so they can focus on the science and doing good work. I help make sure their project gets off the ground and that they’re successful from the very beginning of a study to publication and beyond.”
Policies and regulations and documentation and submissions—they’re just a few of the numerous obstacles Mazanec navigates for researchers who are undertaking a new project. Depending on how much assistance the investigator needs, Mazanec can either point them in the right direction or help them put together all the information to get started.
OnCore, for example, is Dartmouth Health’s clinical trials management system, and Mazanec says it can be burdensome for investigators who aren’t familiar with using the system and have limited time to figure it out because of their clinical responsibilities. She helps investigators—attendings, residents, mentors, “anybody and everybody,” she says—collect the documentation they need to register their studies.
“We don’t expect investigators to be fully aware of everything their study needs all the time,” Mazanec says. “I assist them with what they need, and I review all studies to make sure the research documentation is up to date.”
Mazanec also explores new funding opportunities to help build the department’s research portfolio. When a
grant aligns with an investigator’s project, she helps researchers create and refine their proposal, getting all the documentation together to meet the submission deadline.
“If investigators have ideas about new research or their research as it exists now, I hope they will come to me and chat about it,” Mazanec says. “If I don’t know something, I’m good at finding the answer. I’m a resource to help make people’s lives easier.”
OB/GYN investigators can contact Mazanec for assistance through the research process. Contact her at Morgan.T.Mazanec@hitchcock.org .
This fall, we welcomed Beatrice Ngugi, MSW, as our first departmental social worker. Bea is working alongside of us in the OB/GYN clinics at Dartmouth Hitchcock Medical Center to coordinate care, assist in patient crisis management, and foster a welcoming environment for everyone in our community.
