FP Residency Project

8/14/2019 FP Residency Project

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ENMMC Family Practice ResidencyProgram

A survey of clinical and sociological data of thedeliveries performed at the Residency Program

from July 2001 to December 2002.

by

Patricia Sammarelli, MD

A community health project submitted as partialfulfillment of this program's graduation requirements.

June 24, 2003

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Introduction

The ENMMC Family Practice Residency Program requires its residentsto complete a community health project as a graduation requirement.

Our clinic offers its services to a large group of obstetrical patients that

would otherwise have no access to prenatal care. Thanks to theavailability of indigent funds we can provide this essential healthservice to our community. I intended to describe the characteristics of this category of patients and to estimate the effects of the servicesprovided by us on the health of the mother and the baby. I decided toperform original research using data that were never before describedor analyzed. This survey and analysis has the purpose of answeringthe following questions:

1. What is the ethnic background of our obstetrical patients?

2. How many drop ins do we have per month?

3. What are the percentages of delivery types (nsvd, c/sec, vacuum,other)?

4. What is the marital status of our obstetrical patients?

5. What percentage of our patients do use tobacco, alcohol or drugsduring pregnancy?

6. What is the gestational age at presentation of our patients?

7. What is the gestational age of the babies at delivery?

8. What is the number of prenatal visits of our patients?

9. Is there a relationship between gestational age at presentation andthe number of prenatal visits?

10.What is the age distribution of our obstetrical patients?

11.Is there a relationship between the number of prenatal visits andthe type of delivery?

12.Is there a relationship between gestational age at birth and weightof the baby?

13.What are the percentages of pre-term and-term babies and theirweights?

14.Is there a relationship between the number of prenatal visits andweight of the baby?

15.Is there a relationship between the number of prenatal visits andthe Apgar score?

16.Is there a relationship between the gestational age at delivery and

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2. Number of Drop-ins per Month The following bar chart covers the period spanning from July 2001 toDecember 2002. It shows that the FP Clinic delivered between 2 to 6drop-ins per month. Only once during that 18-month period did we nothave any drop-ins.

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7/01 8/01 9/01 10/0111/011 2/01 1/02 2/02 3/02 4/02 5/02 6/02 7/02 8/02 9/02 10/02 11/02 1 2/020

1

2

3

4

5

6

Drop ins


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3. Delivery Type Percentages The data show that the majority of our deliveries, 65%, are normalspontaneous vaginal deliveries. Second are cesarean sections, 20%,and deliveries using Mityvac, 11%. The rest, 4%, are deliveries whichhad to be induced for several reasons.

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Delivery Type

nsvd 65%c/sec 20%vacuum 11%other 4%


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4. Marital Status The analysis showed that our records do not have the information for

28% of our patients. Based on the available data, we can see that aslight majority of our patients were not married. I have includedsingle, divorced, and separated in the category not-married. Weshould pay more attention to make sure that our charts contain all theinformation. Knowing the marital status of our obstetrical patients willhelp us reach out better to our target population, possibly identifyingrisk factors like lack of a family or available support system.

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Marital Status

married 35%not-married36 %NA 28%


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5. Use of tobacco, alcohol or drugs during pregnancy The data show that 10.2% of our patients used tobacco duringpregnancy, while 2.8% drank alcohol and another 2.8% used drugs.For more than 8% of our patients this information was not recorded intheir charts. To keep in mind is that these data do not reflect the dropin population, for whom the rate of drug/tob/ethanol abuse, is veryhigh.

I would like to point out that I am concerned about the relatively highincidence of smokers. My data analysis shows that patients whoengaged in substance abuse delivered babies with an average weight

of 3,191 grams versus 3,394 grams. This is a decrease in weight of 203 grams.

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Tobacco Alcohol Drugs NA0

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

0.09

0.1

0.11

0.12

Use of Tobacco, Alcohol and Drugs


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6. Gestational Age at Presentation The data analysis shows that the majority of our patients, 59%, havetheir first prenatal visit at or before their 15 th week of pregnancy.Between 16 and 30 weeks we have 23% of our patients.

Patients who start their prenatal visits after 30 weeks are 18% of thetotal. As we can see, more than half of our patients show up duringthe first trimester. However, there is still a large percentage of patients that need to be informed of our services, possibly through ourlocal media. Some of these late presentations are simply transfersfrom other locations.

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1->5 3% 6->1031%

11->1525%

16->2012%

21->256%

26->305%

31->359%

36->409%

0

5

10

15

20

25

30

35

Gestational Age at Presentation

Weeks of Pregnancy

Abuse Non-abuse0

500

1000

1500

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2500

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3500

4000

3190.63393.8

Substance Abuse versus Non-abuse


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8. Number of Prenatal Visits Most of our patients have 8-to 10 prenatal visits. However, there is asignificant number of patients that have more, up to 21, or less, as fewas 1 visit.

We can notice that there is a wide distribution of the number of visits. The optimal situation would actually be the opposite. We want all ourpatients to show up early in their pregnancy and have the appropriatenumber of prenatal visits which would results in them obtainingoptimal prenatal care and help us to identify possible risk factors.

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0 2 4 6 8 10 12 14 16 18 20 22012345

6789

101112131415

Number of Prenatal Care Visits

Number of Visits


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9. Relationship between Gestational Age at Presentation and Number of Prenatal Visits As expected, there is an inverse relationship between the gestationalage at presentation and the number of prenatal visits. The trend lineon the chart shows this relationship.

Using this graph, we can divide our obstetrical patients in three groups:the first group corresponds to the dots to the left of 15 weeks and at orabove the trend line. We can call these our goal patients. Theycome early and often. The second group correspond to all dots to theright of 15 weeks of gestational age. We can call these our late-comers. We need to reach out to them to convince them to start theirprenatal visits earlier. The third group corresponds to the dots to theleft of 15 weeks and below the trend line. These patients come to ourclinic early but rarely, and some of them disappear from the scene.Despite our emphasis on educating them to come regularly and tellingthem how crucial it is do so, it seems that we are not getting the

results that we would like to.

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0 5 10 15 20 25 30 35 40 450

5

10

15

20

25

GA pres and PNV#

GA pres

P N

V #


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10. Age Distribution The data show that the great majority of our patients, 68%, are 25years of age or younger. Note that 4% are 15 or younger.

This seems to be typical of the kind of population that we serve.

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10->15 16->20 21->25 26->30 31->35 36->40 40->450

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

0.5

0.04

0.32 0.32

0.13 0.14

0.040.01

Age of Patients


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11. Relationship between Number of Prenatal visits and Type of Delivery I have investigated the possibility of a relationship between thenumber of prenatal visits and the type of delivery. The hypothesis isthat the greater the number of visits, the greater the chance of anatural spontaneous vaginal delivery. The data actually shows theopposite. As we can see, when the number of visits are more than 10,the percentage of nsvd is 41%, while the percentage of c/sections is48%.

The possible reason for this is that patients with medical issues tend tohave more prenatal visits especially those patients who are deliveredby repeat c/sections. Of course, we should not come to the conclusionthat having more prenatal visits is detrimental.

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nsvd+ 1-5

nsvd+ 6-10

nsvd+ 11-15

nsvd+ 16-20

nsvd+ 21-25

Row 6 c/s ec+ 1-5

c/sec+ 6-10

c/sec+ 11-15

c/sec+ 16-20

c/sec+ 21-25

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

PNV# and Delivery Type


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12. Relationship between Gestational Age at Birth and Weight of the Baby As expected, there is a direct relationship between gestational age andweight of the baby as shown in the following chart. Since the weight of the baby is a function of many variables besides gestational age atbirth, such as nutrition, substance abuse, genetics, etc., we can seethat the dots are quite scattered, even though the trend is very clear.

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30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 450

500

000

500

000

500

000

500

000

500

000

GA and Weight

GA (weeks)


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13. Percentages of Pre-term and Full-term Babies and their Weights

The great majority of the babies delivered by us, 84%, are at term andare AGA. Of the pre-term babies, a good percentage, 12% still haveacceptable weight.

Three percent of our babies are pre-term and weigh less than 2,500grams, while only 1% are low for gestational age.

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0.84

0.010.12

0.03GA & Weigth

>38 wk >2500 g>38 wk


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14. Relationship between the Number of Prenatal Visits and Weight of the Baby Since the weight of the baby is function of many variables,aspreviously discussed, the plot of the number of visits versus theweight of baby is very scattered.

However, the graph shows a positive correlation, even though it isslight. The reason for this is open to many interpretations. However,mothers that tend to take care of their fetuses, are also more likely tohave more prenatal visits, which allows us to better monitor the healthof the mother and the fetus. In general the weight of the baby is agood indicator of its health except in cases of babies born to diabeticmothers.

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0 5 10 15 200

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3500

4000

4500

5000

PNV# & Weight


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15. Relationship between Number of Prenatal Visits and Apgar Score

The relationship between the number of prenatal visits and the Apgarscore is not clear. There might simply not be any relationship, or therelationship is masked by the fact that most scores are 8 and 9,making it difficult to calculate any correlation.

Nonetheless, there seems to be a slight correlation, which is morepronounced at 5 minutes than at 1 minute.

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0 5 10 15 20 250

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PNV# & APGAR

APGAR 1 minLogarithmic Re-gression for APGAR1 min

APGAR 5 minLogarithmic Re-gression for APGAR5 min


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16. Relationship between Gestational Age at Delivery and Apgar Score Unlike the former correlation study, this one is more pronounced.

There is a clear correlation between gestational age at birth and Apgarscores at both 1 minute and 5 minutes. This is not surprising, since weknow that Apgar reflects how healthy the baby is, which is greatlyinfluenced by the gestational age.

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30 35 40 450

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10

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GA & APGAR

APGAR 1 minLogarithmic Re-gression for APGAR1 minAPGAR 5 minLogarithmic Re-gression for APGAR5 min


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17. Diabetic Patients I have calculated the percentage of diabetic obstetrical patientsdefined as abnormal 1 hour glucose challenge test and abnormal 3hour glucose tolerance test. The results are shown in the following barchart. We can see that the number of diabetic patients in ourpopulation is significant. The group of not available data (NA) includesmissing data, which means that the tests were not performed becausewe failed to request them (minority), as well as late presentations forwhich the test was not performed.

Conclusions

This survey and analysis of original data obtained from the records of our clinic and ENMMC has shown new correlations and confirmedpreviously known ones. The results of this analysis will give us a betterunderstanding of the population we serve and their needs.

Data

The data collected are shown an PDF file named prog-data.pdf.

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Diabetic Normal NA-0.2

0

0.2

0.4

0.6

0.8

1

0.09

0.73

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Diabetic Patients

FP Residency Project

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