ENMMC Family Practice Residency

Program

A survey of clinical and sociological data of the

deliveries performed at the Residency Program
from July 2001 to December 2002.
by

Patricia Sammarelli, MD

A community health project submitted as partial

fulfillment of this program's graduation requirements.

June 24, 2003

1
Introduction
The ENMMC Family Practice Residency Program requires its residents
to 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 the
availability of indigent funds we can provide this essential health
service to our community. I intended to describe the characteristics of
this category of patients and to estimate the effects of the services
provided by us on the health of the mother and the baby. I decided to
perform original research using data that were never before described
or analyzed. This survey and analysis has the purpose of answering
the 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 drugs
during 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 and
the 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 and
the type of delivery?
12.Is there a relationship between gestational age at birth and weight
of the baby?
13.What are the percentages of pre-term and-term babies and their
weights?
14.Is there a relationship between the number of prenatal visits and
weight of the baby?
15.Is there a relationship between the number of prenatal visits and
the Apgar score?
16.Is there a relationship between the gestational age at delivery and

2
 the Apgar score?
17.What is the percentage of diabetic patient in our OB population?

Materials and Methods

I collected the data pertaining to the mother from the records kept at
the Family Practice Clinic and the data pertaining to the baby from the
records kept at the Labor and Delivery Ward of the Eastern New
Mexico Medical Center. The data collected did not contain any
personal information. The data were tabulated, analyzed and charted
using a free spreadsheet, OpenOffice Calc. The period of study
spanned from July 2001 to December 2002. Unfortunately, several
charts were not available at the clinic probably because they were
purged from the system.

Results and Discussion

The data analysis that I performed to answer the questions listed in the
introduction show the following results:

1.Ethnic Background of Obstetrical Patients

Our patients belonged to only two ethnic groups. The vast majority,
87%, were Hispanic, while the rest, 13%, were Anglo.

Ethnic Groups

Hispanic 87%
Anglo 13%

From personal experience I can state that a significant portion of our

obstetrical patients only speak Spanish. This would suggest the
importance of proficiency in Spanish on behalf of the staff of our clinic.

3
2. Number of Drop-ins per Month
The following bar chart covers the period spanning from July 2001 to
December 2002. It shows that the FP Clinic delivered between 2 to 6
drop-ins per month. Only once during that 18-month period did we not
have any drop-ins.

Drop ins
6

0
7/01 8/01 9/01 10/01 11/01 12/01 1/02 2/02 3/02 4/02 5/02 6/02 7/02 8/02 9/02 10/02 11/02 12/02

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

Delivery Type

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

5
4. Marital Status
The analysis showed that our records do not have the information for

Marital Status

married 35%
not-married
36%
NA 28%

28% of our patients. Based on the available data, we can see that a
slight majority of our patients were not married. I have included
single, divorced, and separated in the category not-married. We
should pay more attention to make sure that our charts contain all the
information. Knowing the marital status of our obstetrical patients will
help us reach out better to our target population, possibly identifying
risk factors like lack of a family or available support system.

6
5. Use of tobacco, alcohol or drugs during pregnancy
The data show that 10.2% of our patients used tobacco during
pregnancy, while 2.8% drank alcohol and another 2.8% used drugs.
For more than 8% of our patients this information was not recorded in
their charts. To keep in mind is that these data do not reflect the drop
in population, for whom the rate of drug/tob/ethanol abuse, is very
high.
Use of Tobacco, Alcohol and Drugs
0.12
0.11
0.1
0.09
0.08
0.07
0.06
0.05
0.04
0.03
0.02
0.01
0
Tobacco Alcohol Drugs NA

I would like to point out that I am concerned about the relatively high
incidence of smokers. My data analysis shows that patients who
engaged 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.

7
 Substance Abuse versus Non-abuse
4000

3500 3393.8
3190.6

3000

2500

2000

1500

1000

500

0
Abuse Non-abuse

6. Gestational Age at Presentation

The data analysis shows that the majority of our patients, 59%, have
their first prenatal visit at or before their 15th week of pregnancy.
Between 16 and 30 weeks we have 23% of our patients.
Gestational Age at Presentation
35

30

25

20

15

10

0
1->5 3% 6->10 11->15 16->20 21->25 26->30 31->35 36->40
31% 25% 12% 6% 5% 9% 9%
Weeks of Pregnancy
Patients who start their prenatal visits after 30 weeks are 18% of the
total. As we can see, more than half of our patients show up during
the first trimester. However, there is still a large percentage of
patients that need to be informed of our services, possibly through our
local media. Some of these late presentations are simply transfers
from other locations.

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7. Gestational Age at Delivery
The mode of the distribution of the gestational age at delivery is
between 40 and 41 weeks.
Weeks at Delivery
40

36

32

28

24

20

16

12

0
34 35 36 37 38 39 40 41 42 43 44

Few patients deliver after this time, while the distribution to the left of
the mode is less steep, meaning there is a wider distribution of the
gestational ages.

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

Number of Prenatal Care Visits

15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
0 2 4 6 8 10 12 14 16 18 20 22

Number of Visits
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 our
patients to show up early in their pregnancy and have the appropriate
number of prenatal visits which would results in them obtaining
optimal prenatal care and help us to identify possible risk factors.

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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 gestational
age at presentation and the number of prenatal visits. The trend line
on the chart shows this relationship.

GA pres and PNV#

25

20

15
PNV#

10

0
0 5 10 15 20 25 30 35 40 45
GA pres
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 or
above the trend line. We can call these our “goal” patients. They
come early and often. The second group correspond to all dots to the
right 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 their
prenatal visits earlier. The third group corresponds to the dots to the
left of 15 weeks and below the trend line. These patients come to our
clinic early but rarely, and some of them ”disappear” from the scene.
Despite our emphasis on educating them to come regularly and telling
them how crucial it is do so, it seems that we are not getting the
results that we would like to.

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

Age of Patients
0.5

0.45

0.4

0.35 0.32 0.32

0.3

0.25

0.2

0.15 0.13 0.14

0.1

0.05 0.04 0.04

0.01
0
10->15 16->20 21->25 26->30 31->35 36->40 40->45
This seems to be typical of the kind of population that we serve.

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11. Relationship between Number of Prenatal visits
and Type of Delivery
I have investigated the possibility of a relationship between the
number of prenatal visits and the type of delivery. The hypothesis is
that the greater the number of visits, the greater the chance of a
natural spontaneous vaginal delivery. The data actually shows the
opposite. 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 is
48%.
PNV# and Delivery Type
0.4

0.35

0.3

0.25

0.2

0.15

0.1

0.05

0
ns vd ns vd ns vd ns vd ns vd Row 6 c/s ec c/s ec c/s ec c/s ec c/s ec
+ 1-5 + 6-10 + 11- + 16- + 21- + 1-5 + 6-10 + 11- + 16- + 21-
15 20 25 15 20 25

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

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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 and
weight of the baby as shown in the following chart. Since the weight of
the baby is a function of many variables besides gestational age at
birth, such as nutrition, substance abuse, genetics, etc., we can see
that the dots are quite scattered, even though the trend is very clear.

GA and Weight
5000

4500

4000

3500

3000

2500

2000

1500

1000

500

0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45

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 and
are AGA. Of the pre-term babies, a good percentage, 12% still have
acceptable weight.
GA & Weigth
0.03
0.12
0.01

>38 wk >2500 g
>38 wk <2500 g
<38 wk >2500 g
<38 wk <2500 g

0.84

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

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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,as
previously discussed, the plot of the number of visits versus the
weight of baby is very scattered.

PNV# & Weight

5000

4500

4000

3500

3000

2500

2000

1500

1000

500

0
0 5 10 15 20
However, the graph shows a positive correlation, even though it is
slight. The reason for this is open to many interpretations. However,
mothers that tend to take care of their fetuses, are also more likely to
have more prenatal visits, which allows us to better monitor the health
of the mother and the fetus. In general the weight of the baby is a
good indicator of its health except in cases of babies born to diabetic
mothers.

16
15. Relationship between Number of Prenatal Visits
and Apgar Score
The relationship between the number of prenatal visits and the Apgar
score is not clear. There might simply not be any relationship, or the
relationship is masked by the fact that most scores are 8 and 9,
making it difficult to calculate any correlation.
PNV# & APGAR
11

10

8
APGAR 1 min
7 Logarithmic Re-
gression for APGAR
6 1 min
APGAR 5 min
5 Logarithmic Re-
gression for APGAR
4 5 min

0
0 5 10 15 20 25

Nonetheless, there seems to be a slight correlation, which is more

pronounced at 5 minutes than at 1 minute.

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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 Apgar
scores at both 1 minute and 5 minutes. This is not surprising, since we
know that Apgar reflects how healthy the baby is, which is greatly
influenced by the gestational age.
GA & APGAR
12

10

8 AP GAR 1 min
Logarithmic Re-
gression for APGAR
1 min
6 AP GAR 5 min
Logarithmic Re-
gression for APGAR
5 min
4

0
30 35 40 45

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17. Diabetic Patients
I have calculated the percentage of diabetic obstetrical patients
defined as abnormal 1 hour glucose challenge test and abnormal 3
hour glucose tolerance test. The results are shown in the following bar
chart. We can see that the number of diabetic patients in our
population is significant. The group of not available data (NA) includes
missing data, which means that the tests were not performed because
we failed to request them (minority), as well as late presentations for
which the test was not performed.

Diabetic Patients
1

0.8 0.73

0.6

0.4

0.18
0.2
0.09

-0.2
Diabetic Normal NA

Conclusions
This survey and analysis of original data obtained from the records of
our clinic and ENMMC has shown new correlations and confirmed
previously known ones. The results of this analysis will give us a better
understanding 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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