Characterizing Research Hotspots and Trends in Simulation-Based Training in Obstetrics and Gynecology 1961-2024: A Bibliometric Analysis

Introduction

Simulation-based training (SBT) has a long-standing application in health professions education and has become an integral component thereof.¹ SBT offers a non-actual yet realistic and immersive teaching and learning environment.² Within the environment, simulated clinical scenarios closely mirror real-world clinical practices and clinical trainees are able to acquire both technical and non-technical skills without the need for direct contact with real patients.^1–3 This effectively averts the occurrence of medical errors and the imposition of risks on patients.³ Moreover, it has been well-established that SBT significantly contributes to enhancing healthcare efficiency.^4,5

Almost all clinical specialties widely adopt SBT as a crucial instrument for professional education.⁶ Specifically, SBT is employed to facilitate the implementation of training programs that center on tasks such as arranging surgical schedules, providing assistance in pain alleviation during childbirth, promoting cognitive-behavioral therapies in mental healthcare, and developing interpersonal skills among individuals with autism spectrum disorder.⁶

However, when compared with other clinical specialties, obstetrics and gynecology (O&G) is characterized by an extremely high level of complexity and precision in surgical procedures.⁷ There are also growing demands to treat high-risk and emergency patients, necessitating enhanced teamwork and communication.^8,9 As to O&G professional education, several challenges cannot be ignored. For instance, in resource-constrained settings, O&G students often encounter limited access to training in clinical skills prior to commencing clinical practice.¹⁰ This issue may render O&G professional education less effective. Additionally, male students may experience gender bias from actual patients. Such bias can lead to reduced opportunities for interactions with real-world patients.^11,12 SBT holds great potential as an essential tool to tackle these challenges.

Although guidelines acknowledge the role of SBT in health professions education,⁶ challenges persist at both macro and micro levels. At the micro level, issues regarding simulation content, feedback quality, and assessment reliability remain.^13–15 At the macro level, challenges include insufficient funding for SBT implementation, an uneven distribution of qualified SBT educators, and limited adoption of advanced technologies.^13,14

To guide targeted solutions, it is imperative to elaborate on the current status and patterns of research on SBT in O&G professional education. Bibliometric analysis can well serve as an analytical method.¹⁶ By employing bibliometric analysis, researchers can examine published studies and their meta data to identify research hotspots, track trajectories of research topics, assess the impact of published works and uncover hidden collaboration patterns.¹⁶

Although several bibliometric analyses have been conducted in the fields of SBT and O&G respectively,^17–19 they rarely focused on the application of SBT in O&G professional education. Moreover, given the global shortage of O&G health professionals,^20,21 how to train individuals into qualified health professionals to meet the demands of O&G practice and how to expedite the adoption of SBT in O&G professional education, remain crucial questions to answer. Therefore, new insights into research dynamics are needed to guide educational practice, research practice and funding policies within this field. In this bibliometric study, we aimed to examine the current research hotspots, dynamics and intellectual structure of the application of SBT in O&G professional education. We also aimed to explore factors associated with the impact of research in this field.

Materials and Methods

This study was reported following the preliminary guideline for reporting bibliometric reviews of the biomedical literature (BIBLIO).²² Since this study did not use primary data directly collected from human samples, ethical review was not required.

Data Sources and Search Strategy

Searches for relevant research were performed in the Web of Science Core Collection. This database was chosen over Scopus and PubMed because it provides comprehensive academic indexes (covering life science and education science) and has a strict index selection process that ensures quality. The following search terms and formula were used: TS = ((simulat*) AND (training* OR education* OR learning* OR teaching* OR study OR studies OR instruction*) AND (obstetrics OR gynecology)). Searched records were restricted to articles, reviews, and proceedings papers. Additionally, an English language filter and a date filter (up to 2024) were applied. Searches were performed on December 3, 2024.

Inclusion and Exclusion Criteria

Studies were included if they were original articles (quantitative, qualitative, or mixed-method research), review articles, and proceeding papers. Studies were excluded if they were duplicates, retracted articles, comments, perspectives, theses, abstracts, and news. Studies were also excluded if they were not related to SBT or O&G.

Data Analysis

Mean (standard deviation) and frequency(percent) were calculated to summarize research performance, including the most productive authors, countries, dominant keywords, and highly cited publications. Visualizations were generated to illustrate temporal trends in publication volume, total and average citations, keyword occurrence, and journal contributions. Collaborations among authors, countries, and institutions were analyzed and visualized to present collaborations. The conceptual structure of the studied field was examined using multiple correspondence analysis (MCA).

To investigate determinants of research impact (total citations through 2024), a zero-inflated negative binomial regression model was developed. This type of model was selected based on the following considerations: 1) our study outcome was more like count data rather than continuous data; 2) the Vuong test confirmed that the zero-inflated model was preferred; and 3) over-dispersion was observed (dispersion parameter = 14.35).

The predictors included years since being published, author count, funding status, cited reference count, publishers, research types, research areas, science citation index expanded (SCIE)-indexed status, usage count since 2013 (full-text link clicks), and corresponding authors’ locations. The final model was estimated with a robust standard error. All analyses were performed with R version 4.0. The bibliometric analyses were performed with the R package “bibliometrix”.²³

Results

Study Selection

The study selection process can be found in Figure 1. In brief, initial searches returned 1105 records. Sequential exclusions were applied as follows: 55 records not belonging to articles, reviews, or proceeding papers, 48 non-English publications, four duplicates, and 18 domain-irrelevant studies. Finally, 980 records were included in the analyses.

Figure 1 Study selection process.

Research Performance

The earliest publication identified dates back to 1961, with a single study recorded. The latest year when any publication can be found was 2024, in which 87 studies were published. Citations per publication ranged from 0 to 304, with an average of 13.31. The most productive country was the USA, with 410 (41.84%) studies being published, followed by the UK with 71 (7.24%) and Canada with 56 (5.71%) (Figure 2A). The most productive author was Sorensen JL (14 studies, 1.43%), followed by Nitsche JF (12, 1.22%) and Goffman D (11, 1.12%) (Figure 2B). As to the H index (Figure 2C), Sorensen JL had the highest score at 11, followed by Ottesen B (8), Nitsche JF (7), and Schreuder HWR (7). The top ten keywords were simulation, obstetrics, training, education, gynecology, medical education, laparoscopy, simulation training, patient safety, and surgical education (Figure 2D). The ten most cited publications and associated total citations are listed in Table 1. The most relevant journal was the Journal of Minimally Invasive Gynecology.

Table 1 Top ten Highly Cited Publications

Figure 2 Research performance on simulation-based training in obstetrics and gynecology professional education. (A) Top 10 countries/locations with the highest productivity; (B) Top 10 authors with the highest productivity; (C) Top 10 authors with the highest H index; (D) Top 10 keywords.

Research Dynamics

A significant surge was found in the number of publications in 2008; in that year, 21 studies were published with an increase of 15 relative to 2007. Following 2008, a significant increasing trend can be observed. The first year when there were over 100 studies published was 2022 (Figure 3A). The annual growth rate of publication volume was 7.35%.

Figure 3 Research dynamics on simulation-based training in obstetrics and gynecology professional education. (A) Temporal trends in publication volume; (B) Temporal trends in average article citations; (C) Temporal trends in total citations; (D) Cumulative occurrences of keywords; (E) Cumulative occurrences of journals; (F) Temporal trends in author productivity. Notes: Journal 1: journal of minimally invasive gynecology; Journal 2: simulation in healthcare-journal of the society for simulation in healthcare; Journal 3: journal of surgical education; Journal 4: obstetrics and gynecology; Journal 5: international journal of gynecology and obstetrics; Journal 6: American journal of obstetrics and gynecology; Journal 7: European journal of obstetrics and gynecology and reproductive biology; Journal 8: surgical endoscopy and other interventional techniques; Journal 9: bmc medical education; Journal 10: cureus journal of medical science.

The average number of citations peaked in 2009 at 53.57 citations per publication; thereafter, this statistic presented a gradual decline. Total citations reached three peaks in 2009, 2012, and 2013, with values of 1125, 1096, and 1203 in those years respectively (Figure 3B and C).

The top three keywords over the analyzed period were skills, simulation, and performance. Before 2018, the occurrence of keyword performance dominated that of keywords skills and simulation; this situation was reversed after 2018 (Figure 3D). Other keywords, including obstetrics, education, and management, consistently remained dominated by the top three keywords throughout the analyzed period.

Although the American Journal of Obstetrics and Gynecology published the earliest relevant research among the top 10 journals, its dominance in publication volume was replaced by the Journal of Minimally Invasive Gynecology and Simulation in Healthcare from 2012 onwards. Notably, the Cureus Journal of Medical Science emerged as a significant source of relevant publications starting in 2019, with a sharp increase in annual output (Figure 3E).

Most authors published the majority of their work between 2013 and 2020. Most authors showed a nearly even distribution of total citations over time, except for Sorensen JL and Oei SG (Figure 3F).

Co-Word and Collaboration Analysis Results

The keyword skills had mild-to-strong connections with several other keywords, such as simulation, performance, obstetrics, education, and impact. The keywords management, care, delivery, shoulder dystonia, and trial were interconnected. The keyword surgery had mild-to-strong connections with the keywords validation, curriculum, and operating room. The keyword residents had strong connections with surgical skills (Figure 4).

Figure 4 Co-word and collaboration analysis results.

The USA was the most productive country, collaborating primarily with the UK and Canada. German-speaking countries, including Germany, Switzerland, and Austria also showed some level of collaboration. Collaboration among other countries seemed to be uniformly weak (Figure 4).

Conceptual Structure Analysis Results

MCA identified three clusters of keywords. The first cluster was primarily related to communication, teamwork, and patient safety. The second cluster focused on medical students/residents and surgical training. The third cluster consisted of midwifery and interprofessional (Figure S1).

Factors Associated with Total Citations

The zero-inflated model results showed that with a one-unit increase in years since being published, the odds of receiving zero citations decreased by 82% (OR = 0.18, p<0.001). Other examined factors seemed to show no significant effects (all p values > 0.05, Table S1).

The count model results showed that each additional year since being published was associated with a 14% increase in total citations (RR = 1.14, p<0.001). Funded research was associated with a 28% increase in total citations (RR = 1.28, p = 0.001). Every additional ten cited references was associated with a 6% increase in total citations (RR = 1.06, p = 0.004). Relative to education-oriented research, O&G-oriented research was associated with a 29% increase in total citations (RR = 1.29, p = 0.024). SCIE-indexed research was associated with a 70% increase in total citations (RR = 1.70, p <0.001). Every additional ten usage counts since 2013 was associated with a 48% increase in the total citations (RR = 1.48, p < 0.001). Other examined factors seemed to show no significant effects (all p values > 0.05, Figure 5).

Figure 5 Forest plot for factors associated with total citations. Abbreviations: RR, relative risk; CI, confidence interval; O&G, obstetrics and gynecology; SCIE, science citation index expanded.

Discussion

Using a bibliometric analysis approach, we investigated research hotspots and trends in SBT in O&G professional education. Our study findings could offer an important opportunity to uncover the profiles and dynamics of the domain investigated.

Main Findings

We found that publications increased over time in this field, peaking in 2022. This peak is likely attributable to COVID-19. Social quarantine during this period forced most SBT programs to shift from offline to online delivery,^24,25 driving the adoption of advanced technologies such as virtual reality (VR), augmented reality (AR), and pre-recorded videos for SBT implementation.^26,27 This transition highlighted the urgent need to address challenges in adapting SBT to digital platforms. Concurrently, researchers prioritized developing hybrid SBT delivery models that integrate online and offline approaches.²⁶ In parallel, given the significant impact of COVID-19, exploring how to utilize SBT to enhance health professionals’ capacity to address emergent issues was also a critical research focus.^28,29

The three countries with the highest publication outputs were the USA, the UK, and Canada. Among the top 10 most productive countries, China and Brazil were the only economically developing countries. This pattern may highlight the uneven global distribution of research activity and advancement in SBT in O&G professional education. Evidently, research efforts on SBT remain concentrated in high-income economies.³⁰ This is not beyond expectation. Economically developed countries demonstrate significant advantages in resources and budgets that can be invested in simulation infrastructure, professional development for educators, and institutional capacity building. Leading medical institutions in the USA and the UK, for instance, maintain cutting-edge simulation settings equipped with high-fidelity simulators and auxiliary systems.^31–33 Such technologies enable the replication of complex O&G clinical scenarios with exceptional fidelity, thereby advancing research on SBT in O&G professional education. Additionally, robust funding mechanisms and research ecosystems that prioritize healthcare education innovation create sustained momentum for scholarly exploration in this domain.^34,35

However, the relatively limited research outputs in developing economies may not indicate a reduced demand for SBT in these regions. Conversely, this situation underscores an urgent imperative to scale both implementation and scholarly assessment of SBT.^10,36,37 A WHO report shows that maternal mortality is higher in developing economies than in high-income countries.³⁸ This elevated maternal mortality can be partly attributed to health professionals’ insufficient clinical skills and competencies in managing obstetric emergencies such as postpartum hemorrhage. Continuous provision of training in essential skills, such as midwifery, cesarean section, and management of postpartum hemorrhage, within a safe and realistic environment is crucial for enhancing health professionals’ clinical capabilities and improving maternal outcomes.^39–41

Research Hotspots

We determined research hotspots by simultaneously considering the top 10 publications with the highest citations, the top 10 keywords, and the three research clusters identified in the MCA.

Hotspot 1: SBT for O&G Surgical Education

The prominence of keywords “surgical education” and “laparoscopy” indicates the research community’s prioritization of SBT in developing surgical competencies. In particular, the emphasis on laparoscopy reflects a research focus on minimally invasive techniques, which demand high precision and specialized training.⁴² This observed research hotspot can also be supported by the publication with the highest citation, which evaluated the effectiveness of the VR simulator in improving procedural quality in gynecological surgeries.⁴³

Traditional laparotomy often involves large incisions, which can cause significant trauma to the body.^44,45 Minimally invasive surgeries such as laparoscopy and hysteroscopy only require a few small incisions or natural orifices in the abdomen or vagina, greatly reducing tissue damage.^46–48 Furthermore, many patients with gynecological diseases require fertility preservation. Minimally invasive surgeries enable minimization of the impact on fertility, and maximization of the chance of conception after surgery.⁴⁹ SBT has been demonstrated to be effective in helping trainees acquire such skills in minimally invasive surgeries.⁴²

Hotspot 2: SBT and Patient Safety

The keywords “simulation”, “training” and “patient safety” imply a research priority in examining the role of SBT in ensuring patient safety. We also identified a research cluster that consisted of communication, teamwork, and patient safety. This finding could further suggest that the research community pays substantial attention to investigating the effectiveness of communication and teamwork via SBT on patient safety. Of the 10 identified highly cited publications, several explored the effectiveness of teamwork training in reducing medical errors and improving patients’ safety in O&G practice.^50–52 Admittedly, ensuring patient safety is of utmost importance. SBT has been recognized as an effective strategy to achieve this goal.^53,54 For example, ensuring patient safety in O&G practice requires complex communication with patients and their families. This is because O&G clinical decisions often involve high complexity due to the need to balance reproductive health and systemic health, necessitating a shared decision-making process that actively involves patients and their families.^55,56

Hotspot 3: SBT for Interprofessional Education for Midwifery Practice

Midwives play a significant role in the well-being of mothers and children during the prenatal, labor, and postnatal phases.^57,58 SBT can simulate various clinical scenarios specific to midwifery, such as labor and delivery, emergency situations (like shoulder dystocia), and patient consultations, thereby enhancing the practical competencies of midwives. Moreover, midwives can practice interpersonal communication and collaboration by interacting with other healthcare professionals, such as obstetricians, nurses, and neonatologists in a controlled and shared environment. For example, a simulation of a high-risk delivery requires midwives to communicate effectively with the entire healthcare team, coordinate efforts for safe delivery, and manage potential complications. Earlier studies demonstrated the positive effectiveness of simulation-based interpersonal training among midwives.^59,60

Factors Associated with Total Citations in This Field

O&G-oriented publications tended to receive more citations than education-oriented ones. This discrepancy may stem from differences in the nature of the subjects. In other words, publishing and disseminating study results is more urgent in medical and clinical research areas than in educational research areas. This is because clinical research is related to life and death, directly dealing with human health and survival. Once new therapies or interventions are validated to be of great effectiveness and value, they can be applied to clinical practice by as many health professionals as possible via publishing the study results. We also found that SCIE-indexed publications received more citations than those not indexed in SCIE. This may result from more stringent selection criteria for SCIE-indexed publications. Such criteria could lead to higher quality, visibility and dissemination efficiency, which could expose the publications to a wider audience.

Research Trends Forecast

Although we identified that surgical skills acquisition via SBT was one research hotspot, we failed to determine a research hotspot regarding the assessment of the effectiveness of SBT. One of the major challenges in SBT is to generate effective evidence with an objective and patient-related method.⁶¹ Currently, most research focusing on SBT generally relies on subjective and self-reported methods to evaluate trainee-centered outcomes (eg, trainees’ knowledge, self-confidence, and attitude), whereas objective methods for evaluating patient-centered clinical endpoints—such as reduced risk of neonatal asphyxia or improved neonatal survival—remain underutilized.^19,62 Moreover, most SBT assessments focus on trainees’ immediate performance in knowledge, self-confidence, and skills, lacking long-term assessment of sustained impacts on clinical skills and trainees’ careers. Long-term assessment enables more crucial insights into the benefits of SBT.² Specific to O&G, we believe that this research trend would apply as well.

We failed to identify the integration of VR/AR technologies within SBT for O&G professional education as a research hotspot. Previous evidence has shown that VR/AR technologies significantly enhance trainees’ clinical competency and psychological preparedness. Also, VR/AR technologies enable the simulation of clinical scenarios while eliminating the dependency on physical simulators, which can contribute to a cost-effective, reusable, and learner-friendly SBT.⁶³ However, real-world implementation of VR/AR in SBT faces some challenges, and addressing them could become a research hotspot. For example, VR simulators may fail to provide adequate force perception when simulating gynecological bi-manual examinations.^63,64 Given this, we predict that the research topic of optimization of technological adaptability of AR/VR simulators for the O&G specialty would be growing.

Strengths and Limitations

Our study’s limitations should not be ignored. First, we only used a single database for publication searches. While the Web of Science can provide us with high-quality publications, it may miss out on low-quality non-peer-reviewed publications that potentially explore emerging research topics. Also, we excluded studies that were published in languages other than English, which may introduce some level of selection bias. Second, we are unable to be highly confident that the identified research hotspots based on top keywords, highly cited publications, and identified research clusters were actual research focuses. This challenge may be addressed through content analysis of each publication. However, given the large number of included publications (roughly 1000), this was not possible within one study. Third, due to limited data sources, we failed to investigate all possible factors associated with total citations in our regression analyses.

Conclusions

Our study suggests that although this research field is progressing rapidly, publications remain insufficient. Furthermore, as this interdisciplinary domain bridges O&G and education, borrowing strength from each other would benefit both the quantity and quality of research outputs. Finally, future research should focus on objective assessment of SBT in O&G professional education, long-term effectiveness assessment of SBT among O&G trainees, and optimization of implementation of advanced O&G simulators.