2009 Summer Student Research and Clinical Assistantship Program

Research Presentations

Department of Family MedicineAugust 7, 2009

2009 Presentations• Qi Zhang

“Genitourinary tract infections during pregnancy and birth outcomes: A retrospective chart review study of African Americans in Dane County”

• Taya Schairer, Leah Haglund “Infant Mortality Investigation in Dane County”

• Emily Holtan, “Analyzing the Feasibility of Group Prenatal Visits at Wingra Clinic”

• Carla J. Bouwkamp “Gender and Authorship of Papers in Family Medicine Journals 2006-2008”

• Anna Ziemer “Survey of Nipple Shield Use Among Knowledgeable Health Professionals”

Genitourinary tract infections during pregnancy and birth outcomes: A

retrospective chart review study of African Americans in Dane County

Qi ZhangSSRCA 2009 Final SeminarSummer Shapiro Project

Background

• 2002-2004 US black infant mortality rate (BIMR) was 13.3 deaths per 1000 live births

• Wisconsin BIMR was 17.6, higher than the national average

• 2002-2007 Dane Co. BIMR was 6.4– 1990-2001 Dane Co. BIMR was 19.4– ~70% reduction– Why? And why not in the rest of the state?

MMWR Morb Mortal Wkly Rep. 58(20):2009

Decline In BIMR

0

2

4

6

8

10

12

14

16

18

20

22

89-9

1

90-9

2

91-9

3

92-

94

93-

95

94-

96

95-

97

96-

98

97-

99

98-

00

99-

01

00-

02

01-

03

02-

04

03-

05

04-

06

Dane and Wisconsin Infant Mortality From 1989 To 2006

Years

Ra

te p

er

10

00

Liv

e B

irth

s

Dane BlackDane WhiteWI BlackWI White

MMWR Morb Mortal Wkly Rep. 58(20):2009

Background

• In the last decade among African Americans in Dane Co:– Decrease in premature births (<37 weeks

gestation)– Decrease in low birth-weight (<2500g)– Increased survival of premature and low-birth

weight infants• This may be an important factor in the

decrease of Dane Co. BIMR

MMWR Morb Mortal Wkly Rep. 58(20):2009

Role of Genitourinary Tract Infections During Pregnancy

• Certain GU tract infections such as gonorrhea, trichomoniasis, bacterial vaginosis (BV) and urinary tract infections (UTI) have been associated with preterm labor

• Correlated with other adverse outcomes such as pre-term pre-labor rupture of membranes (PPROM), low birth-weight, chorioamnionitis, and neonatal infection

Moodley P, Sturm AW. Semin Neonatol (5): 2000

Study Goal

• Explore whether the decrease in Dane Co. BIMR is related to increased screening, diagnosis, or treatment for GU tract infections

Methods• Labor and delivery records from Meriter and

St. Mary’s Hospital– Currently we have ~260 charts reviewed from

Meriter and ~30 from St. Mary’s

• Comparing 1997 to 2007 records

Methods

• Data obtained include information on:– Demographics, prenatal care, past OB/GYN hx,

maternal health risks (GU tract infections), social hx, complications during labor

• Data collected by 4 study staff members: 2 medical students and 2 OB/GYN MD’s– Charts were reviewed together initially to

establish reliability

Methods• Outcome measures:

– BIMR– Premature delivery– PPROM– Low birth-weight– GU tract infection diagnoses, treatment, test of cure– Demographic measures

• Independent variable– Time (1997 vs. 2007)

Results and Discussion

• Pending

Study Limitations• Small N’s – very few cases of infant mortality and preterm

labor in Dane Co.• Treatment and/or test of cure were not always documented

– STI’s may have be treated elsewhere• Documentation of ethnic origin or nationality is not always

clear in the case of African immigrants• Charts were not randomly pulled: at Meriter Hospital they

were by timing of delivery• Missing and incomplete charts• Due to time constraints, we were only able to review charts at

Meriter

Acknowledgements

• Gloria Sarto, MD• Laura Berghahn, MD• Amanda Schmeil, MD• Murray Katcher, MD • Carley Zeal, BS• Shapiro Scholarship• MERC grant

Infant Mortality Investigation

Taya Schairer and Leah HaglundMentor: Dr. Lee Dresang

Introduction

In 2004, US infant mortality rate 6.78 per 1000 live births while the Black Infant Mortality Rate (BIMR) was 13.25 per 1000 live births

Between 2000-2004, WI infant mortality was 6.7 per 1000 live births while the BIMR was 17.6 per 1000 live births (1)

In Dane county, African American infant mortality has decreased 67% since 1990’s while other areas, like Racine County, have not seen such declines (9.4 per 1,000 live births for 1990-2001 to 6.4 for 2002-2007) (1)

Reducing Infant Mortality Disparities In Wisconsin

The goal of the larger project is to investigate improved birth outcomes in Dane County and apply what is learned to Racine county and other communities with disparities (2)

Aims to achieve goal: Identify risk and protective factors affecting birth outcomes Effects of public programs and policies Impact of healthcare system Compare findings between Racine and Dane County Apply findings to Racine and other communities

Identified Risk Factors of poor birth outcome (2):

Pre-term birth Low birth weight Tobacco, alcohol, and illicit drug use Stressors of life events Socio-demographic characteristics

Clinical Chart Review

Our specific aim is to compare prenatal care and health determinants of African American women in 1997/1998 to 2007 at Wingra and Northeast clinics

Factors we recorded: Maternal age, marital status, education, insurance,

occupation, continuity of prenatal care, attending vs resident as primary provider, obstetric history, pre-conceptual counseling/prenatal vitamins, chronic conditions, pregnancy complications, STIs/infections, genetic disorders, substance use, postpartum characteristics

Methods

Primarily our information was obtained from ACOG sheet with supplemental information on EPIC and in previous chart records

Data recorded on Websurvey

We went through charts together and agreed on findings

Difficulties Encountered

Forms incomplete

Self-report

Subjective nature of questions

Infant Death Record

Project Status

Currently we have collected data for 125 African American Pregnancies 1997/1998: 52 2007: 73

Analysis has not yet been conducted

Preliminary Results

Age 1997/1998: Teenage (35.3%), 20+ (64.7%) 2007: Teenage (29.7%), 20+ (70.3%)

Marital Status 1997/1998: Married (8%), Single (90%), Divorced

(2%) 2007: Married (13.4%), Single (85.1%), Separated

(1.5%)

Preliminary Results

Chlamydia 1997/1998: 12 cases (24.5%) 2007: 9 cases (13.0%)

Gonorrhea 1997/1998: 5 cases (10.4%) 2007: 1 cases (1.5%)

Bacterial Vaginosis 1997/1998: 26 cases (68.4%) 2007: 27 cases (60%)

Trichomonas 1997/1998: 11 cases (35.5%) 2007: 5 cases (11.9%)

Preliminary Results

Gestational Diabetes 1997/1998: 0% 2007: 4 cases (6.15%)

Gestational Hypertension 1997/1998: 1 case (2.1%) 2007: 2 cases (3.0%); 1 case of chronic HTN (1.5%)

Pre-eclampsia 1997/1998: 0% 2007: 4 cases (5.9%)

References

1) MMWR Morb Mortal Wkly Rep. 2009 May 29;58(20):561-5. Erratum in: MMWR Morb Mortal Wkly Rep. 2009 Jul 24;58(28):781

2) Sarto, Gloria E. Reducing Infant Mortality Disparities in Wisconsin.

Analyzing the Feasibility of Group Prenatal Visits at Wingra

Clinic

Emily Holtan, medical student

Suhani Bora, MD and Beth Potter, MD

What are group prenatal visits?

• Two-hour group visit with doctor offers:• 6-8 women with similar gestational ages• education and counseling on topics such as:

• labor and delivery, breastfeeding, proper nutrition, and parenting

• access to community resources

• social networking

* Centering Pregnancy, a non-profit organization will come to your site and implement the group visits for a large fee

What does the literature say about group prenatal visits?

• Improved birth outcomes by • reducing rates of preterm births• improving prenatal education and satisfaction with

care• increasing rates of breastfeeding initiation

• Research is limited regarding• CenteringPregnancy model versus alternative model• pre/post-natal depression• integrating group visits in a residency clinic

Questions we want to answer• For patients: Is there an interest in group prenatal visitsWhat are the barriers for participation? Do prenatal group provide patients with a stronger knowledge/skill

set regarding prenatal care?

• For residents: Do prenatal group visits provide residents with better

knowledge/skills for providing prenatal care? Will participating in these visit affect their interest in providing

obstetrical care in the future?

Study design

Three aspects of information gathering:For my education: For the clinic: For academic

research:

-Learn how to do a literature review

Chris Hooper-Lane,Ebling Library, Academic Librarian

-IRB writing guidanceMary Beth Plane, Ph.DDFM Senior Scientist

-Support from mentorsDr. Bora & Dr. Potter

(1) Survey prenatal professionals

(2) Survey patients

(3) Survey residents

*requires IRB approval

(1) Survey to prenatal professionals

• Study population: members of STFM (Society of Teachers of Family Medicine)

• Survey given electronically• Targeting people who have implemented group prenatal

visits or were interested• Open-ended questions regarding:

• Are you using the Centering model or not?• Money• Staffing• Recruitment• Resident involvement• Challenges

(2) Survey to Patients

• Study population: pregnant patients at Wingra Clinic (goal= 20 responses)

• Survey given at routine OB visit• Patients recruited thru prenatal educator and MAs • Questions regarding:

• Logistics of Group Visits• Transportation, Employment, Other Children

• Interest in Group Visits• yes, no, or maybe

• Confidence/ Knowledge regarding Prenatal Care

(3) Survey to Residents

• Study population: UW-Madison Family Medicine residents (goal= 20 responses)

• Survey given electronically• Questions regarding:

• Confidence/Knowledge regarding prenatal care• Quality of residency training received in prenatal care• Interest in providing prenatal care in future practice

Results: (1) Survey to prenatal professionals

Qualitative Responses (21 responses)

•Most people used Centering Pregnancy for staff training

•Had those staff train other staff internally

•Overwhelming satisfaction for patient provider, and residents

•At least two residents per group

•Greatest barriers were in funding, scheduling, recruitment

Results: (2) Survey to Patients

(3) Survey to Residents

*application for IRB-exemption submitted July 13th

Discussion

• Conclusions:(1) Prenatal Professional Survey

• Feedback from prenatal professionals was generally positive

• Allowed us to formulate our pilot project design using all of their advice

• Received guidance whether to invest in Centering Pregnancy model

• We have no idea how many sites are doing this, our survey responses may be biased

Limitations(2) Patient Surveys

• Specific to the Wingra patient population only

• Did not include depression screen

• Patients we survey are not the same patients that will be involved in pilot group visits

Limitations: LogisticsSurveys:

• Pending IRB approval• Recruiting patients and residents for survey• Cannot move forward with implementation until know views of

patients, residents

Group Visit Model:• Scheduling• Funding

• For staff training, supplies, etc.

Summer research project• Timing

• Coordinating schedule with Dr. Bora• Project focused on study design rather than study execution

Acknowledgements

• Dr. Suhani Bora, 3rd year resident• Dr. Beth Potter, Faculty• Dr. Mary Beth Plane, Senior researcher

Funding Support: provided by the Department of Family

Medicine for the Summer Student Research and Clinical Assistantship Program

Gender and Authorship of Papers in Family Medicine Journals

2006-2008

Carla J. BouwkampFaculty Supervisor: Sarina Schrager,

MD

Background• Despite increasing numbers of women attending

medical school and completing residencies, women continue to lag behind men in academic achievement

• In 2005, women comprised only 15% of all full professors and 11% of all department chairs

• Studies within surgery, otolaryngology and EM show women authorship is significantly below that of males

• Editorial boards of major medical journals also show that women make up the minority

However, no research has been done in Family Medicine to see if these trends hold!

Methods

• All original articles from the five family medicine journals were reviewed between 2006 and 2008.– American Family Physician (AFP)– Family Medicine Journal (FMJ)– The Annals of Family Medicine – The Journal of Family Practice (JFP)– The Journal of American Board of Family

Practice (JABFP)• Articles were classified based on type of

article, journal, year, and gender of lead author

Methods

• Gender of lead author was determined by name and confirmed by internet research

• Data and statistics were completed in Excel

• A current issue of each of the five journals was reviewed to determine make up of editorial boards.

• The AAMC website was used to gather gender information on faculty positions for family medicine

Results

• 2, 126 articles were reviewed-712 authored by females-1414 authored by males

• 7 authors were thrown out because gender could not be determined

Percentage Breakdown by Genderduring the 2006-2008 period

Percentage Breakdown by Genderfrom 2006-2008

Percentage Breakdown by Type of Article 2006-2008

Percentage Breakdown by Journal 2006-2008

Editorial Boards• Family Medicine• Editor in chief—male (but changing)• Associate editors—1/2 female• Feature editors—3/7 female• Editorial board—11/22 female ( 50%)

• JFP• Editor in chief—male• Associate editors—4/4 male• Assistant editors—3/17 female• Editorial board—3/11 female (27%)

• American Family Physician• Editor—male• Deputy editor for EBM—male• Assistant deputy editor—female• Associate medical editors—4/5 female• Assistant medical editors—2/2 male• Contributing editors—1/3 female• Editorial advisory board—5/49 female

(10%)

• JABFP• Editor—female• Deputy editor—female• Associate editor—1/2 female• Executive editor—male• Editorial board—7/27 female

(25.9%)

• Annals of Family Medicine• Editor—male• Senior associate editor—male• Associate editors—4/6 female• Reflections editor—female• Consulting editor—male• Statistical editor—male• Editorial board—11/28 female

(39.3%)

Percentage Breakdown of Women in Leadership Roles in 2007

Full-Time Faculty who are

women%

Full professors who are women

%

Tenured Faculty who are Women

%

34% 17% 19%

Discussion

• There is a considerable difference between males and females authoring family medicine journal articles.

• There is a considerable difference between males and females comprising family medicine editorial boards.

• There is a considerable difference between males and females holding faculty and tenured positions.

Discussion

• Whether there is a correlation between females authoring less articles and having fewer faculty and tenured positions is still unable to be determined.

• The reason why females author less journal articles or why they have fewer faculty and tenured positions is still unable to be determined.

• Therefore, more research is needed to find out these answers and hopefully improve these trends.

Acknowledgments

• Thank you to Dr. Sarina Schrager for all your guidance and help!

• Thank you to the Department of Family Medicine and Dr. Temte for providing the SSCRA program.

Literature Cited

• Battacharyya N, Shapiro NL. Increased female authorship in ototlaryngology over the past three decades. Laryngoscope 2000;110(3):358-61.

• Hamel MB, Ingelfinger JR, Phimister E, Solomon CG. Women in academic medicine--progress and challenges.N Engl J Med. 2006 Jul 20;355(3):310-2

 • Jagsi R, Tarbell NJ, Henault LE, Chang Y, Hylek EM.

The representation of women on the editorial boards of major medical journals: a 35-year perspective.Arch Intern Med. 2008 Mar 10;168(5):544-8.

 • Jagsi R, et al. The “gender gap” in authorship of academic medical literature—a 35 year

perspective. NEJM 2006;355:281-7.

• Kurichi JE, et al. Women authors of surgical research. Arch Surg 2005;140:1074-77. 

• Li SF, et al. Gender trends in emergency medicine publications. Acad Emerg Med .2007;14(12):1194-6.

• American Academy of Family Physicians. www.aafp.org/afp/. 2006-2008

• Journal of the American Board of Family Practice. www.jabfm.org/. 2006-2008

• The Annals of Family Medicine. www.annfammed.org/. 2006-2008

• Family Medicine Journal. stfm.org/fmhub/fmhub.html. 2006-2008

• American Family Physician. www.aafp.org/afp/. 2006-2008

• AAMC. http://aamc.org/members/wim/statistics/stats08/start.htm

Nipple Shield Use Among Knowledgeable Health Professionals

Presented by Anna Ziemer

Mentor: Dr. Anne Eglash

August 7, 2009

Background Nipple shields are a tool used to help

breastfeeding women No guidelines exist to direct shield use Some health professionals have concerns

about shield use

Images from www.medelabreastfeedingus.com

Goals of the survey:

identify the most common reasons health professionals recommend nipple shields

determine health care professionals’ most common concerns about shield use

identify most common maternal responses to nipple shields

Demographics of survey respondents:

Survey was completed by 490 health professionals

99% female 79% board certified

in lactation 84% from the United

States

Respondents by Age

over 55 years old

(142, 27%)

18-35 years old(48, 9%)

35-45 years old

(120, 23%)

45-55 years old

(210, 41%)

Respondents by Occupation

Physician(43, 8%)

Lactation Consultant(270, 52%)

Nurse(125, 24%)

La Leche League Leader (29, 6%)

Nurse Midwife (16, 3%)

Nur se P r acti tioner (9, 2%)

Dietician (5, 1%)

Other (23, 4%)

Respondents by Specialty

Pediatrics (35, 7%)

Lactation(356, 68%)

Obstetrics/Gynecology(53, 10%)

Neonatology (28, 5%)

Family Medicine (14, 3%)

Child and Family Health (9,2%)

Postpartum Care (8, 2%)

Other (11, 2%)

N/A (6, 1%)

Nipple Shield Use 94% of respondents used nipple shields in

their practiceNipple Shield Use Among Board Certified Lactation Consultants vs. Non-Board Certified Respondents

80

95

20

5

0 20 40 60 80 100

NOT Board Certified

Board CertifiedLactation

Consultants

Percent (% )

DO use nipple shields DO NOT use nipple shields

Top Reasons Respondents Recommend Nipple Shield Use

To help latch infants born less than 35 weeks gestation

To help latch babies born greater than 35 weeks gestation when 3-7 days old

To decrease the work of breastfeeding for infants regardless of age or size

Nipple Shield Use for Term and Near-Term Infants

38% recommend nipple shields for these infants when less than 3 days old

45% recommend the shield for these infants when 3-7 days old

No differences between board certified and non-board certified respondents

Frequency of Nipple Shield Use to Help Latch Babies Born Greater Than 35 Weeks Gestation When 3-7 Days Old

(Selected Occupations)

5

7

45

40

65

37

37

21

9

11

0

4

4

312

0 20 40 60 80 100

Lactation Consultant

Nurse

Physician

Percent (% )

never rarely not uncommon frequently no opportunity

Nipple Shield Use with Pre-Term and Term/Near-Term Infants

Current research shows that the shield can be beneficial for pre-term infants

No studies have been done to show that the shield is helpful for term and near-term infants

Nipple shields may be recommended too often as a ‘quick fix’

Respondents’ Top Concerns About Nipple Shield Use

Lack of follow-up by those handing out the shield

Inappropriate reason for using the shield

Maternal inconvenience of using the shield

Top Maternal Responses to Nipple Shields as Reported by Respondents

The shield is helpful I cannot wait to get rid of the shield I find the shield convenient The shield is inconvenient

Recommendations

Further study is necessary to determine if nipple shield use is safe and effective for term and near-term infants

Clinicians should attempt other techniques to help infants latch before using the shield

Shield packaging should inform mothers about the need for follow-up with a knowledgeable clinician

Thank You

2009 UW-DFM SSRCA