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Prevention of Alcohol-Exposed Pregnancies

The National Association of Nurse Practitioners in Women’s Health (NPWH) supports women’s health nurse practitioners (WHNPs) and other nurse practitioners (NPs) who provide healthcare for reproductive-aged women in the use of evidence-based strategies to prevent alcohol-exposed pregnancies (AEP). Use of these strategies should extend to alcohol screening at least yearly for all adolescent and adult patients. In addition, all sexually active, reproductive-aged women who could become pregnant and who drink alcohol should be counseled about the potentially deleterious effects of alcohol on a developing fetus. They should be advised to use effective contraception to prevent pregnancy or to stop drinking alcohol. Women who are trying to get pregnant should be advised to abstain from drinking alcohol. Pregnant women should be screened for alcohol use at their initial prenatal visit and during each trimester thereafter.1 For those who screen positive for risky alcohol use, NPs should provide a brief behavioral intervention, refer them to specialty services as needed, and plan appropriate follow-up.

Furthermore, NPWH recognizes that early and regular prenatal care for women with alcohol dependence is essential in order to encourage healthy behaviors and provide support and early treatment referrals to reduce risks of harm. Laws that require reporting of alcohol/substance abuse during pregnancy as potential child abuse or ne glect may deter women with alcohol dependence from seeking prenatal care.2,3 Therefore, NPWH opposes policies that require reporting or criminalization of alcohol/substance abuse during pregnancy and supports repeal of existing laws with such mandates. NPWH will provide leadership and collaborate with other organizations and agencies to deliver education and skills training for NPs, develop policies, and conduct and/or support research in a concerted effort to prevent AEP.


Prenatal alcohol exposure is the No. 1 preventable cause of birth defects and intellectual and developmental disabilities in children. Alcohol, a known teratogen, readily crosses the placenta and persists in amniotic fluid after a woman’s serum alcohol level metabolizes to zero. Toxicity is dose related, with the greatest risk to the fetus in the first trimester.With regard to preventing fetal alcohol spectrum disorders (FASD) and other adverse pregnancy and birth outcomes associated with prenatal alcohol exposure, there is no known safe amount of alcohol use at any time during pregnancy

FASD is an umbrella term describing a range of possible effects that include physical, intellectual, behavioral, and learning disabilities and language delays, with lifelong implications for individuals prenatally exposed to alcohol.5 FASD are completely preventable if alcohol is not consumed during pregnancy. But many pregnant women do drink alcohol; the estimated prevalence of FASD in first-grade students in the United States is 2%-5%.The lifetime cost of caring for an infant with fetal alcohol syndrome, a single disorder within the FASD continuum, is approximately $2 million.In addition to FASD, alcohol use during pregnancy is associated with increased risks for spontaneous abortion, intrauterine growth restriction, stillbirth, preterm birth, and sudden infant death syndrome.8

In 2005, the U.S. Surgeon General advised that pregnant women not drink any alcohol, pregnant women who have already consumed alcohol stop doing so, and women considering becoming pregnant abstain from drinking alcohol.9 Despite this recommendation, the number of women who drink alcohol while pregnant has not decreased significantly.10 Ten percent of pregnant women report drinking some amount of alcohol in the past month and 3.1% report binge drinking.10

The fact that about one-half of all pregnancies are unplanned poses a particular challenge to the prevention of AEP. Approximately 3.3 million reproductive-aged women report drinking alcohol in the past month and having sex without using contraception.11 An additional challenge is that only 1 in 6 U.S. adults reports ever having talked with a healthcare professional about their drinking.11 Therefore, many adults may be unaware of the potential risks of alcohol use to their own health or to the health of a developing fetus.

Implications for women’s healthcare and WHNP practice

Strong evidence suggests that alcohol screening and brief intervention (SBI) is effective in reducing risky alcohol use among women of childbearing age.12,13 Leading U.S. healthcare organizations and agencies, including the U.S. Preventive Services Task Force,14 the CDC,11 and the American College of Obstetricians and Gynecologists,15 recommend that alcohol SBI be implemented at least yearly for all adults in primary care settings. Likewise, all pregnant women should be screened at the first prenatal visit and once during each trimester thereafter.

Alcohol SBI involves using a validated screening tool to identify a woman’s drinking patterns, whether her alcohol consumption is creating a health risk for herself or others, and whether she has symptoms of dependency. If at-risk drinking is identified, the NP engages the woman in a brief motivation-enhancing intervention to reduce drinking. The main goal of alcohol SBI is to motivate patients to be aware of their alcohol consumption patterns, understand the associated risks and options for reducing or eliminating the risk, and make their own decisions. Referral to specialty care for further assessment and treatment is made if a woman is unable to moderate risky alcohol use on her own. The CDC’s Planning and Implementing Screening and Brief Intervention for Risky Alcohol Use: A Step-by-Step Guide for Primary Care Practices provides guidance for incorporating universal alcohol SBI within clinical practice.This guide includes information on the use of a variety of screening tools validated for use with adults, including pregnant women.

WHNPs and other NPs who provide healthcare for reproductive-aged women have a responsibility to provide clear, fact-based information regarding risks associated with drinking any amount of alcohol during pregnancy. Furthermore, they have the responsibility to identify women with at-risk drinking habits and provide counseling and referrals for treatment as appropriate.


WHNPs and other NPs who provide healthcare for reproductive-aged women should:

Adopt a non-judgmental respectful approach when broaching the topic of alcohol use.

Counsel each reproductive-aged woman in their care that there is no safe amount of alcohol consumption during pregnancy and provide fact-based information regarding risks.

Provide alcohol screening with a validated screening tool annually and during each trimester of pregnancy.

Provide an evidence-based brief intervention when at-risk alcohol use is identified.

Advise all pregnant women who drink alcohol  to stop doing so.

Advise all women planning a pregnancy who drink alcohol to stop doing so.

Advise all sexually active women who drink alcohol and could become pregnant to use effective contraception to prevent pregnancy or to stop drinking.

Recognize that not all women are able to stop using alcohol without support.

Refer women for additional services if they cannot stop drinking on their own. Know which services are available in the community.

Provide follow-up as needed to monitor women’s drinking, provide encouragement and support, and, if necessary, refer for specialized help.

Be aware of state reporting laws for alcohol/substance abuse in pregnancy and advocate for retraction of legislation that exposes pregnant women with alcohol dependence to criminal or civil penalties.

NPWH will provide leadership and resources to ensure that:

Educational programs for NP students with a population focus that includes reproductive-aged women impart evidence-based knowledge and skill building for the development of competencies to conduct effective alcohol SBI to prevent or address alcohol use during pregnancy.

CE programs are available for NPs to obtain evidence-based knowledge and competencies to conduct effective alcohol SBI to prevent or address alcohol use during pregnancy.


1. Nocon J. Chapter 15: Substance use disorders. In Mattison DR, ed. Clinical Pharmacology During PregnancyAmsterdam: Academic Press, an Imprint of Elsevier; 2013.

2. ACOG. Committee on Health Care for Underserved Women. Committee opinion no. 473: Substance abuse reporting and pregnancy: the role of the obstetriciangynecologist. Obstet Gynecol. 2011;117(1):200-201. Reaffirmed 2014.

3. Guttmacher Institute. Substance Abuse During Pregnancy. Washington, DC: Author; 2014.

4. Mattison DR, ed. Clinical Pharmacology During Pregnancy. Amsterdam: Academic Press, an Imprint of Elsevier; 2013.

5. Sokel RJ, Delaney-Black V, Nordstrom B. Fetal alcohol spectrum disorder. JAMA. 2003;290(22):2996-2999.

6. May PA, Baete A, Russo J, et al. Prevalence and characteristics of fetal alcohol spectrum disorders. Pediatrics. 2014;134(5):855-866.

7. CDC. Planning and Implementing Screening and Brief Intervention for Risky Alcohol Use: A Step-by-Step Guide for Primary Care Practices. Atlanta, GA: CDC National Center on Birth Defects and Developmental Disabilities; 2014.

8. Bailey BA, Sokol RJ. Prenatal alcohol exposure and miscarriage, stillbirth, preterm delivery, and sudden infant death syndrome. Alcohol Res Health. 2011;34(1):86-91.

9. U.S. Department of Health and Human Services. U.S. Surgeon General Releases Advisory on Alcohol Use in Pregnancy. Washington, DC: US Department of Health and Human Services; 2005.

10. Tan CH, Denny CH, Cheal NE, et al. Alcohol use and binge drinking among women of childbearing age – United States, 2011-2013. MMWR Morb Mortal Wkly Rep. 2015;64(37):1042-1046.

11. Green PP, McKnight-Eily LR, Tan CH, et al. Vital signs: alcohol-exposed pregnancies—United States, 2011-2013. MMWR Morb Mortal Wkly Rep. 2016; 65(4):91-97.

12. Bertholet N, Daeppen JB, Wietlisbach V, et al. Reduction in alcohol consumption by brief alcohol intervention in primary care: systematic review and metaanalysis. Arch Intern Med. 2005;165(9):986-995.

13. Jonas DE, Garbutt JC, Amick HR, et al. Behavioral counseling after screening for alcohol misuse in primary care: a systematic review and meta-analysis for the U.S. Preventive Services Task Force. Ann Intern Med. 2012;157(9):645-654.

14. Moyer VA; Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: U.S. preventive services task force recommendation statement. Ann Intern Med. 2013;159(3):210-218.

15. ACOG. Committee on Health Care for Underserved Women. Committee opinion no. 496: At-risk drinking and alcohol dependence: obstetric and gynecologic implications. Obstet Gynecol. 2011;118(2 pt 1):383-388. Reaffirmed 2013.

Approved by the NPWH Board of Directors: August 2016

Boosting HPV vaccination rates: A call to action


Nancy R. Berman, MSN, ANP-BC, NCMP, FAANP, is a nurse practitioner at Michigan Healthcare Professionals in Farmington Hills and a Clinical Instructor in the Department of Obstetrics and Gynecology at Wayne State University School of Medicine in Detroit, both in Michigan.

Intended audience

This continuing education (CE) activity has been designed to meet the educational needs of nurse practitioners, certified nurse-midwives, and other advanced practice clinicians who care for women.

CE approval period

Now through May 31, 2017

Estimated time to complete this activity

1 hour

CE approval hours

1.0 contact hour of CE credit, including 1.0 contact hour of pharmacology content

Needs assessment

Most cervical cancers are preventable. The incidence of cancer related to HPV infection has declined significantly since the inauguration of screening programs in the U.S. more than 50 years ago. However, too many women are still developing cervical cancer, and 4,400 are dying of it each year. More cases of cervical cancer could be prevented with increased uptake of HPV vaccination, increased addition of HPV testing in screening, and improved access to cervical cancer screening in under-screened and unscreened populations.

Goal statement

Nurse practitioners and other advanced practice clinicians who care for women will make a strong recommendation that children aged 11 or 12 get fully immunized against HPV so as to prevent HPV-related diseases in the future.

Educational objectives

At the conclusion of this educational activity, participants should be able to:

1. Understand the efficacy, safety, and immunogenicity of the HPV vaccine, including the new 9-valent vaccine.

2. Be familiar with all of the ACIP guidelines for the HPV vaccine.

3. Boost HPV vaccine uptake in their patient population.

Accreditation statement

This activity has been evaluated and approved by the Continuing Education Approval Program of the National Association of Nurse Practitioners in Women’s Health (NPWH), and has been approved for 1.0 contact hour of CE credit, including 1.0 contact hour of pharmacology content.

Faculty disclosures

NPWH policy requires all faculty to disclose any affiliation or relationship with a commercial interest that may cause a potential, real, or apparent conflict of interest with the content of a CE program. NPWH does not imply that the affiliation or relationship will affect the content of the CE program. Disclosure provides participants with information that may be important to their evaluation of an activity. Faculty are also asked to identify any unlabeled/unapproved uses of drugs or devices made in their presentation.

Nancy R. Berman, MSN, ANP-BC, NCMP, FAANP, has disclosed that she has financial relationships with Hologic and Shionogi.

Disclosure of unlabeled use

NPWH policy requires authors to disclose to participants when they are presenting information about unlabeled use of a commercial product or device or an investigational use of a drug or device not yet approved for any use.


Participating faculty members determine the editorial content of the CE activity; this content does not necessarily represent the views of NPWH or Merck & Co., Inc. This content has undergone a blinded peer review process for validation of clinical content. Although every effort has been made to ensure that the information is accurate, clinicians are responsible for evaluating this information in relation to generally accepted standards in their own communities and integrating the information in this activity with that of established recommendations of other authorities, national guidelines, FDA-approved package inserts, and individual patient characteristics.

Successful completion of this activity

Successful completion of this activity, J-16-02, requires participants to:

1. “Sign In” at the top right-hand corner of the website if you have an NPWH account. You must be signed in to receive credit for this course. If you do not remember your username or password, please follow the “Forgot Password” link and instructions on the sign-in page. If you do not have an account, please click on “Create an Account.”

2.Read the learning objectives, disclosures, and disclaimers on the next page.

3.Check “Agree to Terms” on the next page and then click the “Continue” button.

4. Study the material in the learning activity during the approval period (now through May 31, 2017).

5.Complete the posttest and evaluation. You must earn a score of 70% or better on the posttest to receive CE credit.

6.Print out the CE certificate if successfully completed.

Commercial support

This activity is supported by educational grants from Merck & Co., Inc.

Before reading the article, click here to take the pretest.

Cervical cancer, caused in nearly all cases by human papillomavirus (HPV), is considered a vaccinepreventable disease. Anogenital warts and other forms of cancer can also be caused by HPV, and can be reduced in frequency with HPV vaccination. Despite the proven efficacy and safety of the three available HPV vaccines—one of which targets up to nine different HPV genotypes—only about one-third of girls in the United States have received the three recommended doses. The author reviews information about the HPV vaccines and the guidelines for their use, and offers strategies for healthcare providers to implement in order to improve HPV vaccine uptake in their age-appropriate patients.

Human papillomavirus (HPV) infection is the most common sexually transmitted infection in the United States.Almost all sexually active adults are or will be infected by HPV at some point in their lives, even if they have had sex with only one other person. Although the vast majority of HPV infections are asymptomatic and resolve spontaneously, a few persist and can lead to cancer.2 Persistent infections with oncogenic HPV types can cause cancers of the cervix, vulva, vagina, anus, and penis, as well as the oropharynx. Infection with non-oncogenic HPV types can cause anogenital warts.

About 79 million persons in the U.S. are already infected with HPV, and 14 million persons acquire HPV infection each year.3 An estimated 17,600 women and 9,300 men receive a diagnosis of an HPVrelated cancer each year. For U.S. women, cervical cancer is the most common HPV-related cancer; approximately 11,000 women are diagnosed with it annually and 4,400 women die of it. For U.S. men, oropharyngeal cancer is the most common HPV-related cancer; about 7,200 U.S. men are diagnosed with it each year.

In an Annual Report to the Nation on the Status of Cancer, Jemal et alreported that many types of HPV-related cancers were on the rise, some disproportionately affecting certain racial and ethnic minorities. For example, from 2000 to 2009, oral cancer rates increased 4.9% for Native American men, 3.9% for white men, 1.7% for white women, and 1% for Asian men. Anal cancer rates doubled from 1975 to 2009. Vulvar cancer rates rose for white women and African-American women and penile cancer rates increased among Asian men.

Most cervical cancers are preventable. The incidence of this disease has declined significantly since the inauguration of screening programs in the U.S more than 50 years ago.5 However, too many women are still developing cervical cancer, and 4,400 are dying of it each year. More cases of cervical cancer could be prevented with increased uptake of HPV vaccination, increased addition of HPV testing in screening, and improved access to cervical cancer screening in under-screened and unscreened populations.

HPV vaccines

For decades, the best that healthcare providers (HCPs) could offer patients in terms of lowering their risk for developing HPV-related cancers were screenings for cervical cancer precursors and for anal pre-cancers and cancers (in highrisk populations) and inspection for vulvar pre-cancers and cancers. But in June 2006, the FDA approved the first vaccine to prevent disease caused by any of four HPV genotypes: 6 and 11, which cause anogenital warts; and 16 and 18, which are the most common causes of cervical cancer.6

Three HPV vaccines are on the market in the U.S. (Table).The bivalent HPV (2vHPV), quadrivalent HPV (4vHPV) and 9-valent HPV (9vHPV) vaccines each target HPV 16 and 18, the types that cause about 70% of cervical cancers and most other HPV-linked cancers in women and men.3,7 The 9vHPV vaccine targets five additional cancer-causing types (HPV 31, 33, 45, 52, 58), which account for about 15% of cervical cancers. The 4vHPV and 9vHPV vaccines also protect against HPV 6 and 11, the types that cause 90% of anogenital warts.


Clinical trials have suggested that HPV vaccines, if used optimally, could likely prevent most cervical cancers.2 Of 10,000 young women vaccinated as part of clinical trials before they could have been exposed to oncogenic forms of HPV, none developed HPV 16- or 18-associated cervical lesions, which are precursors to invasive cancer.8,9 HPV vaccines have been shown to prevent other HPV 16- or 18-associated anogenital pre-cancers and HPV 6- or 11-associated genital warts with similar efficacy.9,10 Women who received the 2vHPV vaccine as part of a clinical trial had a much lower prevalence of oral HPV infection than did participants who had not received the HPV vaccine.11

In a study reported in March 2016, Markowitz et al12 analyzed 4vHPV type prevalence (i.e., types 6, 11, 16, and 18) in cervicovaginal specimens from females aged 14- 34 years in NHANES (National Health and Nutrition Education Survey) in the pre-vaccine era (2003-2006) and during 4 years of the vaccine era (2009-2012). Within 6 years of HPV vaccine introduction, there was a 64% decrease in 4vHPV type prevalence among females aged 14-19 and a 34% decrease in 4vHPV type prevalence among those aged 20-24 years. There was no decrease in 4vHPV type prevalence in older age groups.

Because the HPV vaccine has been available for only 10 years, it will take a while to assess its efficacy in preventing invasive cancers that take years or decades to develop following persistent infection.


Three population-based safety studies of the HPV vaccine have been conducted in the U.S.13-15 These studies have identified no serious safety concerns, although one study showed an increased risk of syncope on the day of vaccination and skin infections in the 2 weeks following vaccination.15 Gee et al12 evaluated the risk for venous thromboembolism (VTE) in persons aged 9-26 years, and found no increased risk of VTE following vaccination with the 4vHPV vaccine. Chao et al14 found no association between 4vHPV vaccine use and 16 autoimmune conditions.

According to ongoing safety monitoring by the CDC, most reports of adverse reactions to the vaccine are non-serious.16 Among the 7.6% of reports classified as serious, the most common side effects are headache, nausea, vomiting, and fever. Syncope is a common non-serious problem in both female and male adolescents who receive the HPV vaccine. Of note, syncope is not specific to the HPV vaccine. It is recommended that after receiving the injection, patients remain seated for 15 minutes before leaving the clinical setting.


Drolet et al17 conducted a systematic review and meta-analysis of 20 studies in 9 high-income countries to assess population-level consequences and herd effects after female HPV vaccination programs  and to verify whether the high efficacy reported in randomized controlled trials was materializing in real-world situations. The investigators found that in countries with female vaccination coverage >50%, HPV type 16/18 infections decreased significantly, by 68%, and anogenital warts decreased significantly, by 61%, between pre- and post-vaccination periods in girls aged 13-19 years. In addition, significant reductions were recorded in HPV types 31, 33, and 45 in this age group of girls, suggesting cross-protection. Furthermore, the incidence of anogenital warts declined significantly in boys younger than 20 years and in women aged 20-39 years, suggesting herd effects. In countries with female vaccination coverage <50%, significant reductions in HPV types 16/18 infection and in anogenital warts occurred in girls younger than 20, with no indication of cross-protection or herd effects.

Duration of immunity

According to a 2011 review, the HPV vaccine was found to provide protection against persistent cervical HPV 16/18 infections for up to 8 years—the maximum time of research follow-up at that point.18 More will be known about the total duration of protection as research continues. To date, no evidence suggests waning immunity such as that seen with the menin go coccal conjugate vaccine, which now requires a second dose. Multiple cohort studies are in progress to monitor the duration of immunity.

More about the 9-valent vaccine

To gain the recent endorsement of the CDC’s Advisory Committee on Immunization Practices (ACIP), the 9vHPV vaccine had to demonstrate efficacy, immunogenicity, and safety.19 In particular, the newest vaccine had to show efficacy in terms of preventing infection and disease related to HPV 31, 33, 45, 52, and 58 in a susceptible population and of generating an antibody response to HPV 6, 11, 16, and 18 that was non-inferior to that generated by the 4vHPV vaccine. Studies conducted by Joura et al20 and Luxembourg et al21 showed precisely that.

In 7 pre-licensure studies, the 9vHPV vaccine was evaluated in more than 15,000 females and males.22 In some studies, the 9vHPV vaccine was compared with the 4vHPV vaccine. The 9vHPV vaccine caused slightly more reactions— primarily swelling and redness—at the injection site. As with the 4vHPV vaccine, side effects associated with the 9vHPV vaccine were generally mild. A video summarizing information about the 9vHPV vaccine is available here.

ACIP guidelines

Routine immunizations for 11- and 12-year-olds include HPV vaccination. HCPs should recommend the HPV vaccine on the same day and in the same way as the other vaccines for preteens.

Age, gender, and vaccine type

ACIP recommends that routine HPV vaccination be initiated at age 11 or 12, although the vaccination series can be started as early as age 9.19 Vaccination is also recommended for females aged 13-26 and for males aged 13-21 who have not been vaccinated previously or who have not completed the 3-dose series. HPV vaccination is recommended through age 26 years for men who have sex with men and for immunocompromised persons (including those with HIV infection) who have not been vaccinated previously or have not completed the 3-dose series. Females should receive the 2vHPV, 4vHPV, or 9vHPV vaccine and males should receive the 4vHPV or 9vHPV vaccine. The dosing schedule for each vaccine type is shown in the Table. If the vaccine schedule is interrupted, the vaccination series need not be restarted.


ACIP recommends that, whenever possible, the HPV vaccination series for females be completed with the same HPV vaccine product.16 If vaccination providers do not know or do not have available the HPV vaccine product previously administered to a given patient, or are in settings transitioning to the 9vHPV vaccine, any available HPV vaccine product may be used to continue or complete the series for females for protection against HPV 16/18, and the 4vHPV or 9vHPV vaccine may be used to continue or complete the series for males.19 There are no data on the efficacy of fewer than 3 doses of 9vHPV.

Concomitant administration with other vaccines

HPV vaccine can be administered at the same visit as other ageappropriate vaccines, such as the tetanus/diphtheria/acellular pertussis (Tdap) and quadrivalent meningococcal conjugate vaccines.16 Giving all indicated vaccines togethe at a single visit increases the likelihood that adolescents will receive each vaccine on schedule. Each vaccine should be administered using a separate syringe at a different anatomic site.

History of sexual abuse or assault

The newest vaccination schedule issued by ACIP recommends that the HPV vaccine be given as early as age 9 or 10 if a child has a history of sexual abuse.23 Studies estimate that 1 in 4 girls and 1 in 20 boys will experience sexual abuse before age 18.

HPV vaccine coverage rates

The HPV vaccine has been available for almost 10 years. Despite its proven efficacy and safety, HPV vaccine coverage rates have been low. In 2012, only 53.8% of 13- to 17- year-old girls had received the first HPV vaccine dose and only 33.4% had completed all 3 recommended doses.24 These rates were substantially lower than HPV vaccine coverage rates in other high-income countries such as Australia and the United Kingdom (71.2% and 60.4%, respectively; Figure).2 More recent reports have indicated some improvement in HPV vaccine coverage rates. For example, in 2014, among girls aged 13-17, 60.0% received at least one dose and 39.7% received the 3 recommended doses.25 The improvement was laudable but insufficient: 6 of every 10 girls in this country are not fully vaccinated against HPV.

Strategies to boost vaccination rates

And, thus, a call to action: Concerted efforts are needed to increase HPV vaccine uptake and achieve its potential to prevent cancers.2 These efforts should promote both initiation of the first dose and completion of all 3 doses for age-eligible adolescents, as well as eligible young adults. What can HCPs do to improve vaccination rates?

1. Keep up to date on what you can do to prevent HPV-related cancers

The CDC launched a new website, HPV: You are the key to cancer prevention, for HCPs so that everything about HPV vaccination is found in one place. The website is easy to navigate; it has only 1 page and 3 tabs: Know the Facts, Commit to the Cause, and Lead the Conversation.26 The recommendations described in items 2, 3, 4, and 6 were also derived from this new CDC website.26

2. Make a strong recommendation

The high coverage rates for the Tdap and meningococcal conjugate vaccines suggest that most preteens and teens are not only going to see their HCP, but they are also getting at least one of the recommended adolescent vaccines.25 However, according to the 2013 National Immunization Survey-Teen, one-third of the parents of girls and more than half of the parents of boys said their child’s HCP had not recommended HPV vaccination—the No. 1 reason for failure to vaccinate their children.27,28 Had the HPV vaccine been administered during visits when another vaccine was given, vaccination coverage for ≥1 dose could have reached 91% by age 13 for adolescent girls born in 2000.25 Evidence shows that an HCP recommendation to get vaccinated is the single most influential factor in determining whether parents gets an immunization for their child!24 HCPs should provide clear and strong recommendations that the HPV vaccine series be given to preteens.

3. Seize the day

Timing is everything.26 Making a strong pitch for preteens to be vaccinated is necessary, but not sufficient. HCPs should take advantage of appropriate opportunities to vaccinate their preteen patients against HPV—for example, during school or camp physical exams—when these patients are still coming in for regular office visits. Once these patients go to college or to work, they are less likely to see their HCP for yearly checkups. To make a timely recommendation, HCPs should do it the same way and the same day that they recommend the Tdap and meningococcal vaccines.

4. Use a reminder system

Reminder systems shown to increase HPV vaccination rates include a reminder letter and direct messaging via automated text, prerecorded voice, and/or postcard.29,30

5. Educate mothers during their routine visits

Another useful strategy is to educate mothers when they are being screened for cervical cancer about the role of HPV infection in cervical cancer. HCPs should explain to mothers that they are undergoing an HPV test to determine whether the virus is present on their cervix, and that their preteen daughters or sons can be vaccinated to be protected from being infected by the HPV types in the vaccine. HCPs can simply say: “HPV is the cause of cervical cancer. We are screening you with the HPV test and the Pap test to detect any existing HPV infection or cervical pre-cancers, which we can then treat to keep them from progressing to cancer. But we can vaccinate your daughters and sons to prevent HPV infection and therefore prevent cervical pre-cancer and cervical cancer.”

6. Address parents’ specific concerns

If a parent’s main concern is side effects, HCPs can say: “Vaccines, like any medication, can have side effects. With the HPV vaccine, the most common side effect is pain and redness at the site of the injection. These symptoms should go away quickly. In addition, the HPV vaccine has not been linked to any serious or long-term side effects.”26 If a parent’s main concern is effect on fertility, HCPs can say, “No scientific data suggest that getting the HPV vaccine has any effect on future fertility. In fact, not getting the HPV vaccine can put a woman’s fertility in jeopardy. Persistent HPV infection can cause cervical cancer, and the treatment of cervical cancer can leave a woman unable to have children. Even treatment for cervical pre-cancer can put a woman at risk for problems with her cervix during pregnancy, causing preterm delivery or other problems.”

7. Hand out written materials

Written materials are helpful in supporting patient education. Patients can refer to them later, after they have spoken to you. Many written materials are available in languages other than English. Spanish-language materials are particularly easy to find. Patient factsheets regarding the HPV vaccine are available on the CDC website.


Considering how effective the HPV vaccine will be in preventing cervical cancer, as well as other HPV-related cancers in both females and males, virtually all preteen girls and boys and all eligible young women and men should be immunized. Vaccination uptake rates, although increasing slowly, are still much too low. These rates will rise dramatically only when HCPs across the country heed the call to action and educate parents about the efficacy and safety of this vaccine and take advantage of opportunities to initiate and complete administration of the 3-dose series.


1. Centers for Disease Control and Prevention (CDC). Genital HPV Infection – Fact Sheet. Last updated February 3, 2016.

2. President’s Cancer Panel Annual Report 2012-2013. Accelerating HPV Vaccine Uptake: Urgency for Action to Prevent Cancer.

3. CDC. Clinician Factsheets. HPV Vaccination Information for Clinicians. Page last updated December 29, 2015.

4. Jemal A, Simard EP, Dorell C, et al. Annual Report to the Nation on the Status of Cancer, 1975-2009, featuring the burden and trends in human papillomavirus (HPV)-associated cancers and HPV vaccination coverage levels. J Natl Cancer Inst. 2013; 105(3):175-201.

5. National Cancer Institute. A Snapshot of Cervical Cancer: Incidence and Mortality. November 5, 2014.

6. FDA. June 8, 2006 Approval Letter — Human Papillomavirus Quadrivalent (Types 6, 11, 16, 18) Vaccine, Recombinant.

7. CDC. Clinician Factsheets. Supplemental Information and Guidance for Vaccination Providers Regarding Use of 9- Valent HPV Vaccine. Page last updated December 29, 2015.

8. Lehtinen M, Paavonen J, Wheeler CM, et al. Overall efficacy of HPV-16/18 AS04-adjuvanted vaccine against grade 3 or greater cervical intraepithelial neoplasia: 4-year end-ofstudy analysis of the randomised, double-blind PATRICIA trial. Lancet Oncol. 2012;13(1):89-99.

9. Muñoz N, Kjaer SK, Sigurdsson K, et al. Impact of human papillomavirus (HPV)-6/11/16/18 vaccine on all HPVassociated genital diseases in young women. J Natl Cancer Inst. 2010;102(5):325-339.

10. Palefsky JM, Giuliano AR, Goldstone S, et al. HPV vaccine against anal HPV infection and anal intraepithelial neoplasia. N Engl J Med. 2011; 365(17):1576-1585.

11. Herrero R, Quint W, Hildesheim A, et al. Reduced prevalence of oral human papillomavirus (HPV) 4 years after bivalent HPV vaccination in a randomized clinical trial in Costa Rica. PLoS One. 2013;8(7):e68329.

12. Markowitz LE, Liu G, Hariri S, et al. Prevalence of HPV after introduction of the vaccination program in the United States. Pediatrics. 2016;137(3):1-9.

13. Gee J, Naleway A, Shui I, et al. Monitoring the safety of quadrivalent human papillomavirus vaccine: findings from the Vaccine Safety Datalink. Vaccine. 2011;29(46):8279-8284.

14. Chao C, Klein NP, Velicer CM, et al. Surveillance of autoimmune conditions following routine use of quadrivalent human papillomavirus vaccine. J Intern Med. 2012;271(2):193-203.

15. Klein NP, Hansen J, Chao C, et al. Safety of quadrivalent human papillomavirus vaccine administered routinely to females. Arch Pediatr Adolesc Med. 2012;166(12):1140-1148.

16. Markowitz LE, Dunne EF, Saraiya M, et al; CDC. Human papillomavirus vaccination: recommendations of the Advisory Committee on Immunization Practices (ACIP)MMWR. 2014;63(RR-05):1-30.

17. Drolet M, Bénard É, Boily MC, et al. Population-level impact and herd effects following human papillomavirus vaccination programmes: a systematic review and metaanalysis. Lancet Infect Dis. 2015;15(5):565-580.

18. Romanowski B. Long term protection against cervical infection with the human papillomavirus: review of currently available vaccines. Hum Vaccine. 2011;7(2):161-169.

19. Petrosky E, Bocchini JA Jr, Hariri S, et al; CDC. Use of 9-valent human papillomavirus (HPV) vaccine: updated HPV vaccination recommendations of the Advisory Committee on Immunization Practices. MMWR. 2015;64(11):300-304.

20. Joura EA, Giuliano AR, Iversen OE, et al. A 9-valent HPV vaccine against infection and intraepithelial neoplasia in women. N Engl J Med. 2015;372(8):711-723.

21. Luxembourg A, Bautista O, Moell er E, et al. Design of a large outcome trial for a multivalent human papillomavirus L1 virus-like particle vaccine. Contemp Clin Trials. 2015;42:18-25.

22. Markowitz L. CDC Expert Commentary. Common Questions About 9-Valent HPV Vaccine. Medscape Pharmacists. June 22, 2015.

23. Advisory Committee on Immunization Practices (ACIP). Recommended Immunization Schedules for Persons Aged 0 Through 18 Years. United States. 2016.

24. CDC. Human papillomavirus vaccination coverage among adolescent girls, 2007-2012, and postlicensure vaccine safety monitoring, 2006-2013—United States. MMWR. 2013; 62(29):591-595.

25. CDC. National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13–17 Years — United States, 2014. MMWR. 2015;64(29):784- 792.26. CDC.

26. Human Papillomavirus (HPV). For Clinicians. HPV: You Are the Key to Cancer Prevention. Page last updated September 30, 2015.

27. CDC. Human Papillomavirus Vaccination Coverage Among Adolescents, 2007–2013, and Postlicensure Vaccine Safety Monitoring, 2006–2014 — United States. MMWR. 2014;63(29):620-624.

28. Newitt VN. HPV vaccination: Are you doing enough to make sure that your patients are protected? Nurse Pract Perspect. 2015;2(4):32-36.

29. Chao C, Preciado M, Slezak J, Xu L. A randomized intervention of reminder letter for human papillomavirus vaccine series completion. J Adolesc Health. 2015;56(1):85-90.

30. Bar-Shain DS, Stager MM, Runkie AP, et al. Direct messaging to parents/guardians to improve adolescent immunizations. J Adolesc Health. 2015;56(5 suppl):S21-S26.

Effectiveness of portal notification in completion of cervical cancer screening in 50- to 65-year-old female family medicine patients


Cervical cancer screening (CCS) guidelines changed in 2012.Women aged 50-65 years who have undergone CCS annually for decades may be unaware of these changes. Even if they are aware of the changes, they may be confused about the new time frames or forget to schedule their CCS as recommended. During routine office visits, nurse practitioners can provide education regarding the new guidelines. In addition, use of a patient web portal to remind women about scheduling their CCS may aid in eliminating the problem— that is, patients’ lack of awareness of and confusion about CCS.2

A large Northeast Florida Family Medicine Department was the setting for a quality improvement (QI) project to implement and evaluate a strategy to improve CCS screening rates in women aged 50-65 years. An existing but underutilized patient web portal was used to send invitations to patients to schedule overdue CCS. The QI project’s main purpose was to determine whether utilizing a computer-based patient portal for notification of overdue CCS would facilitate scheduling the appointment and completing the screening.


An electronic query of 598 charts of patients aged 50-65 years was completed. Inclusion criteria were being in the designated age group and being at least 6 months overdue for CCS. Patients with histories of hysterectomy, cervical disorders, off-campus gynecologic care, treatment for a current cervical disorder, or no portal enrollment were excluded.

A letter of invitation for CCS was developed. Individual invitations were sent privately through the clinic web portal communication system. Patients were asked to reply through the web portal and schedule an appointment within 2 months of receiving the notice. After 2 weeks, a second letter was sent to non-responders and to account for non-delivery of the first letter. Subsequent responses were collected for 2 more weeks. Project endpoints included response time from the first and second invitations and completion of CCS appointments. Confidence intervals (CIs) were calculated for each endpoint.


Among the 598 patients whose charts were reviewed, 88 (14.7%) met criteria for the project and received an invitation letter via the web portal. Of the 88 patients, 25 responded to the invitation, scheduled an appointment, and completed the CCS within a 2-month time frame (28%; 95% CI, 19%-39%). Of the 25 patients, 22 responded to the first invitation (mean response time, 5.7 days) and 3 to the second invitation (mean response time, 1 day), which met the endpoint criterion of making a response within 14 days. The remaining 63 patients (72%) did not meet the endpoint criteria of opening and/or responding to the invitation within 14 days and/or making and completing a CCS appointment within 2 months of receiving the invitation via the patient portal (95% CI, 61%-81%).


This family medicine department lacked a standardized method of follow-up of patients who were overdue for CCS. As a consequence, there was no way to perform a cohort study for comparison of the web portal notification method with another CCS reminder method.

Implications for women’s health

Cervical cancer may be preventable if recommended screenings are completed according to evidence-based guidelines. Technological advances provide various effective

modes of notifying and scheduling patient screenings. A patient web portal may be successful if utilized routinely and efficiently by provider and patient. 

Karen E. Lane is a graduate of the Doctorate of Nursing Practice program at Jacksonville University and a certified family nurse practitioner at Mayo Clinic Family Medicine Clinic, and Hilary Morgan is Assistant Professor of Nursing at Jacksonville University, all in Jacksonville, Florida.


1. U.S. Preventive Services Task Force. Final Recommendation Statement. Cervical Cancer: Screening, March 2012.

2. Krist A, Woolf S, Rothemich S, et al. Interactive preventive health record to enhance delivery of recommended care: a randomized trial. Ann Fam Med. 2012; 10(4):312-319.

Our Capstone corner department is now our DNP projects: Spotlight on practice department. We invite DNP students or recent graduates to submit reports on their DNP projects for publication consideration. Please see our Guidelines for Authors for more information.

Increasing self-efficacy through patient-centered pre-conception counseling for women with pre-existing diabetes



With a 50% increase in the incidence of pre-existing diabetes mellitus (DM) in pregnant women in less than a decade, DM is now the most common health problem to complicate pregnancy.1 Pre-existing DM in pregnancy with uncontrolled hyperglycemia pre­sents multiple risks. Maternal hyperglycemia during the critical period of organogenesis is linked to congenital malformations, diabetic embryopathy, and fetal death; past the point of organogenesis, it can lead to fetal hypoglycemia, macrosomia, and preterm birth. Maternal risks include accelerated impaired renal function, progression of retinopathy, and pre-eclampsia. The single best intervention for improving fetal/newborn outcomes is good glycemic control before conception and throughout pregnancy. The American Diabetes Association (ADA) recommends providing pre-conception counseling at routine visits for all women of childbearing age with DM.2

During the development of a program to manage DM during pregnancy in a large endocrinology practice, it became evident that many women with DM lacked education and preparation for pregnancy. No standard process existed to provide pre-conception counseling. Without this information, women may have lower self-efficacy for successful DM self-management pre-pregnancy. The goal of this project was to increase patient self-efficacy and knowledge about DM self-management through patient-centered pre-conception education.

A multidisciplinary team, including a diabetes educator, psychotherapist/social worker, dietician, nurse practitioner (NP), physician, and registered nurse, collaborated to develop a pre-conception education packet to be used in a standardized educational approach. Topics included pre-conception glycemic goals, contraception, self-management skills, preparation for pregnancy, and pregnancy expectations and risks. A protocol was developed to offer pre-conception counseling and the education packet to all reproductive-aged women with DM presenting to the practice for regular visits. All seven providers agreed to implement the protocol.

Outcome evaluation methods

A one-group pretest-posttest design was used to evaluate pre/post pre-conception education self-efficacy and knowledge. All reproductive-aged women with DM were offered pre-conception counseling at regular visits over a 10-week period. If pre-conception counseling was provided, the patient was invited to complete an anonymous paper survey. Surveys were returned via mail or an office collection box.

The survey included 8 questions on self-efficacy from the Diabetes Empowerment Scale-Short Form3 and 6 questions on knowledge focusing on the 6 content areas of the pre-conception education packet. Participants were asked to rank their knowledge and self-efficacy levels before pre-conception education and then, on the same survey, rank their knowledge and self-efficacy levels after pre-conception education. The survey was a one-time interaction with participants after they received education.

Chart audits were conducted before and after pre-conception education protocol implementation. The audits evaluated for documentation that pre-conception education had been offered and either provided or declined.


In the 40 surveys returned, 85% of participants reported increased knowledge and 90% reported increased self-efficacy after receiving pre-conception education. Only 25% of 40 charts audited pre-implementation had documentation of pre-conception counseling, whereas 87.5% of 40 post-implementation charts had documentation of counseling.

Implications for women’s health

In DM care centered on patient self-management, women need to feel empowered and engaged in their own care. Providing pre-conception education within a DM practice can have a favorable impact on patient self-efficacy and knowledge. Developing standardized education and processes for healthcare practices to educate patient populations can lead to improved provider compliance and better patient outcomes. NPs who provide care for reproductive-aged women with DM have an important role in providing pre-conception counseling that can help them make informed decisions about DM management and pregnancy planning for optimal maternal, fetal, and new­born outcomes.


The project was limited by the short duration of the study, by the fact that both the pre-survey and the post-survey were completed after the educational intervention, and by the small number of surveys returned.

Jerilynn Spring is an Advanced Practice Provider at Spectrum Health Diabetes and Endocrinology in Grand Rapids, Michigan. Beth Kelsey is Assistant Professor and DNP Program Director at the School of Nursing, Ball State University, in Muncie, Indiana, and editor-in-chief of Women’s Healthcare: A Clinical Journal for NPs.

1. Bell R, Bailey K, Cresswell T, et al; Northern Diabetic Pregnancy Survey Steering Group. Trends in prevalence and outcomes of pregnancy in women with pre-existing type 1 and type 2 diabetes. BJOG. 2008;115(4):445-452.

2. American Diabetes Association. Clinical Practice Recommendations. Diabetes Care. 2014;37(1).

3. Anderson R, Fitzgerald J, Gruppen L, et al. Diabetes empowerment scale-short form (DES-SF). Diabetes Care. 2003;26(5):1641-1642.

Our Capstone corner department is now our DNP projects: Spotlight on practice department. We invite DNP students or recent graduates to submit reports on their DNP projects for publication consideration. Please see our Guidelines for Authors for more information.