RCHC Community Project Abstracts

Back to subject search page or search by preceptor site Cesarean Section Rates at Harney District Hospital Project Date: 8/3/2009 Cesarean section rates as a proportion of live births continue to increase at a rather quick pace in the United States and in many other areas of the world. The CDC reported a 31.8 percent cesarean rate in the United States, a six-fold increase from cesarean section rates of the 1960s and 1970s, and the eleventh consecutive year with an increased rate. Cesarean sections are the most common surgical procedure performed in the United States, 1.4 million in 2007, yet the procedure enjoys very little scrutiny and analysis in comparison to other surgical procedures and medical interventions. Rates of cesarean section vary greatly between geographic areas and within cities at different facilities. Rural areas in the United States tend to have higher cesarean section rates compared with urban areas. This project compiled data from birth logs at Harney District Hospital between 2005 and 2009. The rate of cesarean sections as a proportion of live births increased steadily over this five year period. A further analysis of three years of live births at Harney District Hospital in Burns looked deeper into the indication for cesarean section at each delivery. The physicians who practice obstetrics at HDH had an interest in their cesarean section rate and how it compared with other facilities in Oregon but had not spent the time compiling the data Teen Pregnancy in Milton-Freewater, Oregon Project Date: 4/27/2009 I sought to investigate why the teen birth rate in Milton-Freewater, Oregon is so high by looking at sex education in the schools, learning about the reproductive health resources for teens in the area, and getting the perspective of the teens that live in the area. I have subsequently identified what I believe to be large factors in this problem and have made recommendations on how to improve the education and resources for teens so as to hopefully decrease the teen birth rate over time. I have also made a handout listing reproductive health resources in the area for the teens. Planning for Obstetric Emergencies Project Date: 2/9/2009 Obstetric emergencies can be extremely tense situations especially when the health of a newborn infant or mother may be compromised. Planning for these particular emergencies can help provide efficiency and strategy in implementing the best care for the mother and the newborn. It was found at the Madras Medical Group and Mountain View Hospital in Madras, Oregon that that a basic plan for obstetric emergencies had not been established. For my community project, I helped establish an obstetric emergency medication kit that would be stocked and easily accessible in the OB unit for obstetric emergencies. Having a protocol in place and necessary medications in one easily accessible place can reduce the amount of stress and anxiety that often accompanies such obstetric emergencies. Incidence of Caesarean Deliveries In Rural and Urban Areas: Do our small towns have the answers to solve the bigger issue? Project Date: 2/9/2009 Caesarean births are rising in the US and have been for the last decade. There are likely many contributing factors, and just as likely there is no easy answer for how to reverse this trend. While we may look to patient preference, physician discretion, and changing medical standards for a part of the explanation, this paper attempts to break down this growing problem to see if there are parts of the country that are effected more than others. In the town of John Day, Oregon, the rise in caesarean deliveries has grown high above the national average and it is even higher still above Oregon’s urban center of Portland. But while the effects of this trend towards caesarean delivery is more apparent in this rural setting, the town of John Day may also be able to show us a clue to stopping this rise. In the final year of data analysis, 2007, the town saw a rapid decline in the incidence of its caesarean deliveries, interestingly enough this year also marked the highest number of deliveries, by caesarean or vaginally. While this paper does not leave its reader with the answer for how to solve the rise in caesareans, it does offer the next step in researching how John Day was able to buck the trend. Postnatal and Well-Child Care in Grant County Project Date: 9/8/2008 Grant County is a rural area made up of 7250 residents and is primarily agricultural. The four physicians in John Day provide the primary care, obstetrics, gynecology and emergency care for these residents. Some have been under the impression that the infants they deliver do not always follow up with preventative care in the clinic. In this six week rural rotation it was also observed that some of the infants coming to the doctor were not always coming in for well-child visits. In a respective study of the two years of deliveries at the Blue Mountain Hospital it was found that 96.3% (n=107) of the infants had follow up visits. However, 11.7% of these had limited follow care, some not having any well-child visits. Grant County has the usual barriers to care, such as lack of insurance, low income, etc., but also had some unique rural barriers as well, including a long commute to see a doctor and a lack of physicians in the area. Recently John Day has lost two physicians and is looking to replace them. The absence or limited follow-up care of 15.0% could create a barrier to providing preventative care to the population in Grant County. Obstetric Guide Project Date: 4/28/2008 West Salem Clinic and Total Health Community Clinic in Monmouth primarily serve low income, homeless individuals. Ten percent of the patients require obstetric care which is currently offered by three providers each having 10 deliveries per month on average. The clinics lack educational material that are practical, user friendly, and accessible to the women desiring pregnancy care at these facilities. For the past year, the clinic director has been interested in creating a brief, up-to-date, and readable manual of obstetric care. The goal of the manual is to offer as a free hand out to their patients as a guide for every step of pregnancy and to help providers become more efficient in managing the prenatal visits. Provision and Utilization of IUD’s in Linn County, OR Project Date: 4/28/2008 IUD’s are the most effective and least expensive long-term contraceptive. Outside the US, they are the most common form of birth control used by married women. IUD use in the US was curtailed due to concerns regarding safety after a number of cases of PID and TSS in the 1970’s. Since then, IUD’s have been redesigned to eliminate this safety issue and have an exemplary safety profile. Despite this, IUD’s continue to be underutilized leading to a significant number of unintended pregnancies and unnecessary patient suffering. This study attempted to determine the utilizations and provision of IUDs in Linn County, OR. This was accomplished by phone interview with the practice manager for all Family and Ob/Gyn practices in Linn County and utilized annual billing for IUD procedures from these practices. The results of this study indicate that in Linn County 1.2% of women between the ages of 15-49 use IUDs (vs 2% US and 13-14% worldwide) and that only 32% of qualified providers are actually providing IUDs. Based on the results of this study, Samaritan Health (which manages 90% of Family and Ob/Gyn practices in Linn County) agreed to organize an IUD CME course to encourage Linn County providers to increase IUD use. Prenatal care resources available for low-income women in Grants Pass, OR Project Date: 12/31/2007 Adequate prenatal care is important for both maternal health and pregnancy outcomes. There are various social and behavioral risk factors for inadequate prenatal care, including low-income status. Therefore, it is imperative that resources are available for low-income pregnant women, in terms of access to prenatal care and patient education. According to census data, in 2000, 13.3% of the Grants Pass, OR population was below the federal poverty level ($17,170 for a family of 3 in 2007), and 37.4% were below 200% of the federal poverty level. This is in comparison to 11.6% and 29.6%, respectively, for Oregon as a whole. This study examines various prenatal care and education services available to low-income women in the Grants Pass area. Phone interviews were conducted with a coordinator at the Pregnancy Care Center, a county public health nurse, and a maternity case management nurse. In-person interviews were conducted with a member service manager at Mid-Rogue Independent Physician Association (MRIPA/OHP), and several patients. Printed materials available to patients were also obtained from Mid-Rogue IPA, a local county health office, and the Pregnancy Care Center. The findings suggest that a variety of prenatal care resources are available for low-income women in Grants Pass, but several barriers exist, including limited staff and funding for programs. Further examination of ways to optimize prenatal care and education at low cost, as well as potential initiatives to increase funding, would be beneficial. The human papillomavirus vaccine: Provider attitudes and barriers to utilization in Roseburg, OR Project Date: 7/2/2007 The human papillomavirus (HPV) is the most common sexually transmitted infection worldwide. In the U.S., 6.2 million new infections occur annually, most in people 15-24 years old. HPV is necessary but not sufficient to cause all cervical cancer, all anogenital warts, and 90% of anal squamous cancers. During 2002, 126 women developed invasive cervical cancer and 45 died of the disease in Oregon. A quadrivalent HPV vaccine (against 6, 11, 16, 18) was FDA approved June 2006 for use in all 11-12 year old females, with a vaccination range of 9-26 years old. The vaccine is 100% effective against cervical cancer and genital warts. Provider attitudes and barriers to vaccination with the HPV vaccine have not been studied recently, so a survey was sent out to 37 health care providers in Roseburg, OR (included MD/DO, PA-C, NP in Family Medicine, OB/Gyn and Pediatrics). 57% of surveys were completed and returned. 71% of providers provide the HPV vaccine. Barriers to vaccinating include cost to both the patient and the provider, as well as difficulty in getting adolescents to come to well visits, and parental tendency to pay less attention to vaccines after age 5. 67% of providers do not agree with mandating the HPV vaccine in Oregon, citing reasons such as cost, insufficient evidence, and questioning government involvement. Although the HPV vaccine is a breakthrough in cancer prevention, more time must be spent investigating barriers to vaccination before mandating the vaccine will be possible. Prevalence and patterns of breastfeeding in Scappoose, Oregon: Development of two handouts Project Date: 7/2/2007 The decision of mothers whether or not to breastfeed their infants has historically been influenced by trends and attitudes within our society rather than by an understanding of the benefits of breastfeeding. Lack of support by the partner or family has been demonstrated to be a major barrier for mothers to continue breastfeeding. This study examines the prevalence and pattern of breastfeeding among infants presenting for well-child exams to the OHSU Family Medicine Clinic in Scappoose, Oregon. The design of this study utilizes both quantitative and qualitative methods and included patient data base research, interviews with providers, childbirth educators and the WIC program nurse as well as observation and direct participation in prenatal and postpartum care clinics and a 4-week childbirth education class. The participation in the clinics and the class allowed for direct patient education opportunities and instruction on breastfeeding techniques. From the findings, two patient handouts were created, one explaining the benefits of and myths about breastfeeding, the other given detailed instruction on breastfeeding techniques and partner support. The handouts were available during the final days of the rotation and will assist the clinicians whenever women request information on breastfeeding during their visits to the clinic and serve as a guide to one-on-one instruction about breastfeeding techniques. In addition, they are to be made available during subsequent childbirth education classes and to provide a framework for future breastfeeding classes. The state of teen pregnancy in Josephine County Project Date: 4/30/2007 Nationwide Oregon ranked 16th (50th = highest) for teen pregnancy rates in 2004. The trend is an overall decrease in the number of teen pregnancies across the nation, the state, and the counties. Despite favorable statistics, further assessment of resources available in Josephine County are concerning for inadequate sexuality education, lack of contraceptive access, and few services for young parents. Teen pregnancy has considerable social, economic, and personal costs, and resources need to be re-allocated in order to continue a downward trend in teen pregnancy, rather than a stasis or increase. Antenatal Depression in Klamath Falls, OR; development of a patient handout for use in patient education for at risk women Project Date: 3/19/2007 Depression during pregnancy and in the postpartum period is a major public health concern in the United States affecting approximately 20% of all pregnant women. This study attempted to assess the process of identifying women at risk and educating them on available options in the Klamath Falls Family Practice Residency Clinic. The design was observation of family physician's, obstetrician's, and psychiatrist's interaction with pregnant patients and patients with mental health problems during a five week rotation in a high-risk area. One faculty psychiatrist is the primary referral source for patients with medication questions. For counseling services patients are referred to Klamath County Mental Health. Patient openness to discuss the topic of depression and mental health concerns in general was observed. While the topic of depression was addressed when a patient initiated the discussion there appeared to be no standard method for screening pregnant patients for depression or discussing treatment options in the event of depression occurring. Also, although there were information handouts regarding depression, there was nothing specifically targeting pregnant or postpartum women. Thus the main goal and final product of this project was development of a patient handout for pregnant patients and those considering pregnancy with concern about depression and anti-depressant treatment. Physical Activity in Harney County, Oregon: Attitudes toward, Self-Assessment of, and Barriers to a Physically Active Lifestyle Project Date: 3/19/2007 Obesity and physical inactivity are quickly becoming major causes of morbidity and mortality in the United States. Rates of obesity and physical inactivity are increasing in the US every year. Citizens of rural communities have higher rates of obesity and physical inactivity than the overall population of the US. In order for small rural communities to take action against this slip into a culture of inactivity and obesity, they must identify trends, needs, and strengths within their communities. My project 1) assesses perceptions of and behaviors that affect health and physical activity, 2) identifies barriers to increased physical activity, and 3) solicits possible governmental/community solutions that can help citizens become more physically active. In order to elicit this information, I conducted interviews with a number of Harney County citizens, including health care staff, patients attending a health care facility, and local citizens in community spaces. I also surveyed patients attending High Desert Medical Center on the topics mentioned above. Surveys and Interviews indicated a number of trends. Citizens had a high personal value for health and physical activity, and had overall high average self-assessed levels of health and physical activity (especially high in the young). There was a slight fall off in self-assessed health and physical activity with increasing age, as well as a large decrease in at-home (as opposed to work/school-related) physical activity levels with increasing age. Walking, gardening, ranch work, bicycling, running, and swimming were the most commonly mentioned physical activities that citizens currently engage in. Swimming, walking, yoga/taichi, gardening, and bicycling were the most commonly mentioned activities that citizens would like to participate in. The most commonly mentioned barriers to physical activity were not having enough time, not having enough money, lack of year round facilities, lack of facilities appropriate to their activity of choice, medical conditions that prohibited their participation in an activity of choice. Most ideas submitted by patients were related to increasing availability of indoor facilities, increasing child-care availability at exercise facilities, and increasing hours of operation of facilities. The Role of the Primary Care Provider in Identifying And Treating Postpartum Depression Project Date: 2/12/2007 Postpartum depression (PPD) is a significant public health problem in the US affecting approximately 1 out of 8 women. Antenatal depression can also occur and when present, is a risk factor for PPD. Although the prevention and treatment of PPD (or perinatal depression) is a public health priority, screening for the disorder is not typically standard of care and therefore PPD is often under diagnosed and inadequately treated placing women, infants and families at risk. Because multidisciplinary primary care providers usually have the most mother/child contact, they are in a prime position to screen for depression and identify risk factors that might lead to PPD. Risk factors such as poor partner/family relationships, lower socioeconomic status, unemployment of self/partner and lack of social support are not uncommon in Eugene, Oregon. The purpose of this project was to: 1. Increase the awareness among the PeaceHealth system (PHS) primary care physicians and midwives of the importance of identifying, treating and/or referring cases of PPD. 2. Introduce a validated screening tool for identifying women at risk of developing or suffering from PPD. 3. Provide a referral list for the treatment and support of PPD. 4. Invite clinician participation in the Lane County PPD Consortium, 5. Provide a PPD screening tool for the PeaceHealth Sacred Heart Hospital labor and delivery social workers. Methods: The patient statistics justifying this project came from 2006 and reflect the number of all PHS physicians’ patients who gave birth at the PHSHH. Information was gathered through conversations with PHS physicians, ancillary staff, the Lane County PPD Consortium and several others. An informational packet (IP) was prepared and distributed to individuals involved with the identification, treatment, referral and quality care of patients with PPD. Findings/Results: Last year, the percentage of diagnosed cases of PPD among PHS primary care physicians’ patients who gave birth at PHSHH was .18%. This is far short of the estimated prevalence of 10-20%. Screening for PPD is not standard of care for primary care doctors in the PHS. Many doctors reported they did not have time to use the IP screening tool and there was a general lack of knowledge of the importance of the role of the primary care provider in addressing the problem of PPD. There were no reported cases of PPD diagnosed during the five week clerkship. Lane County’s Struggle to Help Newborns and Mothers: An Emerging Problem with Promising Solutions Project Date: 2/12/2007 The process of nurturing an uncomplicated pregnancy, delivering a viable and healthy baby, and maintaining the normal growth and maturation of the baby and health of the mother has been the focus of the field of obstetrics and one of the most important medical issues in the United States and worldwide. Previous research has shown that Lane County has the highest perinatal and neonatal mortality rates in the state of Oregon and ranks among the highest in the nation. This study attempted to identify and shed light on the challenges that face mothers and babies in Lane County which contribute to the high perinatal and neonatal mortality rates and evaluate the effectiveness and availability of resources and regional public health institutions that can best serve this specific health care population. The population studied was the female patients who came to the Junction City Medical Clinic along with their newborns for well-child examinations. Each of these patients was asked about challenges that they had faced with regard to receiving adequate prenatal care during their pregnancies. Using patient-provided information further outside research, and dataset analysis, a patient questionnaire was designed to help the expecting mother from Lane County to assess her prenatal needs and to help her better identify the prenatal care resources available to her. The ultimate goal is to be able to better unify and collect these resources and organize them into a neat and convenient handout that provides patient the information they need and also educates them on the necessary prenatal topics. This handout will be made available to Lane County Public Health Department and to the Junction City Medical Clinic to distribute to patients who need prenatal care and health care for both mother and baby after delivery. Educating Expectant Parents: Creation of a Newborn Care Presentation Project Date: 1/1/2007 Many expectant parents anticipate the arrival of their first child with excitement and anxiety. During the months approaching the due date, in addition to advice and reassurance sought from relatives and friends, parenting and birthing classes in communities offer structured education on newborn care to these parents-to-be. In Coos County, Oregon, free educational classes on newborn care, breastfeeding, and children's home safety are offered through the Bay Area Hospital's MOMS (Management of Maternity Services) program. Local pediatricians from North Bend Medical Center and Bay Clinic give presentations on these topical issues in scheduled monthly night courses. The current newborn care class, which consists of a pediatrician talk and bathing and dressing baby demonstrations, includes a stale and outdated slide-show on common and uncommon newborn characteristics from birth marks to neonatal jaundice. MOMS program coordinators and Coos County pediatricians have sensed that this made-in-the-1970s slide-show is ineffective in educating expectant parents and have voiced a need for an engaging and effective presentation on newborn care. The aim of this community project is to create a fresh, interactive, and updated newborn care educational presentation for expectant first-time parents in Coos County. Contraception and Family Planning Education in Madras, Oregon Project Date: 1/1/2007 Jefferson County Oregon has the highest teen pregnancy rates in the state, however, it has doctors that are working to decrease that rate. To help them in the pursuit of this I developed a comprehensive patient handout explaining 17 different contraception options available. The handout is designed to allow patients to make the decisions about which contraceptive methods works best for their lifestyle. I attempted to increase contraception education giving a talk to and getting the handouts to be apart of the materials offered at the county birthing and parenting class. The result was a one page double sided handout that was well received by physicians, nurses, and staff at Madras Medical Group. This handout will help Madras health care professionals guide their patients in making contraception decisions. Patient Centered Education Materials in Klamath Falls Project Date: 10/16/2006 Klamath Falls, OR has a population of around 42,000 people. For many this would call into question it’s designation as a rural community in the state of Oregon. Due to its larger population, however, Klamath Falls provides medical services to many residents of surrounding communities that are completely devoid of medical care. With such a large portion of the patient population located so far from the clinic, I felt that the creation of some patient education materials would help patients learn more about their healthcare outside of the clinic. To accomplish this I created the brochure “Finding Breast Cancer Early with Breast Self Exam” and the handout “Is the new HPV vaccine right for you or your daughter?” The brochure on breast self exam was created in enough time to get some feedback from patients coming in for their annual well woman exam. Overall, they were appreciative of the brochure, but for the most part they ignored it. This didn’t allow for a lot for feedback, and instead it made me question whether my initial assumption about the necessity of such materials was true. I do feel that both of these handouts will be helpful to some of the future patients in my preceptor’s practice, but I also wonder what other ways there are to provide education outside of the clinic. This project definitely got me thinking about other options. Access to Abortion Resources in John Day, Oregon Project Date: 8/7/2006 Current abortion trends indicate that the availability of providers is declining in rural areas. In 2000, 78% of all Oregon counties had no abortion provider. As a result, women must travel longer distances, overcome economic barriers and risk exceeding gestational limitations to terminate their pregnancy. John Day, Oregon is no exception to this trend. Six physicians, 1 NP and 1 PA were interviewed regarding how they provide resources to women seeking abortions. Although no providers exist, 87.5% of the health care workers said they would refer women for an abortion if she asked. In the case of rape or incest, 62.5% said they would “always” include termination in their discussion with the patient. In the past year, the 5 referrals that have been made were from the two female providers. Due to concerns over confidentiality and negative repercussion from the community all agreed that a local abortion provider would not be accepted or used effectively. For rural women, the drawbacks of leaving one’s community, including higher risk of exceeding gestational limitations and money, do not appear to outweigh benefit of anonymity. Improving Birth Outcomes Among Pregnant Adolescents in Klamath Falls, OR Project Date: 7/3/2006 U.S. adolescent pregnancy rates remain higher than any other industrialized nation. According to the Oregon Office of Rural Health, while Klamath Falls’ adolescent pregnancy rates are no higher than the Oregon average, the actual birth rate among pregnant teens is about 1.4 times higher than the Oregon average. Reasons for this have been investigated in prior community health projects, and include lack of access to or knowledge of abortion clinics, as well as the general attitude toward abortion in the community. The focus of this project was the health of those teenage mothers who do choose to give birth. Adolescent pregnancy is associated with various obstetric and birth problems such as premature labor and low-birth weight infants. Reasons for this are related to unique physical, psychological, and social factors present in adolescence. Several prior studies provide a strong argument for instituting specific programs that target this special population in order to improve pregnancy outcomes. Based on these findings, this project used two approaches to improve pregnancy outcomes – a community-based approach and a healthcare provider approach. A teenage pregnancy and parenting workshop course was developed and implemented in the community. Further, a brochure was developed for healthcare providers which provided important information to address in the care of pregnant adolescents. A talk was also given to the residents of Cascades East Family Practice regarding the issue. Teen Pregnancy In Coos County, Oregon Project Date: 5/1/2006 Although the rate of teenage pregnancy continues to decline in the United States, it continues to have a number of serious implications and to place a large burden on society. Not only does becoming pregnant as an adolescent decrease the likelihood of an adequate education and a successful future for the mother, the child often suffers from being raised by a parent who is ill-equipped for the challenge of parenting. While recent trends have shown a decreased teenage pregnancy rate in Coos County, Oregon, recent population studies suggest that this number is now on the rise. In an attempt to identify some of the factors contributing to this alarming trend, I interviewed teenage girls and some of the people who care for them. While several possible causes were identified, main factors included erratic use of contraception and a seeming lack of awareness of the risks of their sexual behavior. No concise educational material was available that discussed these concerns, so a handout was developed to address some of these issues in a matter that was appropriate for teenagers. High-Risk Obstetrics in Grant County, Oregon. (Nearest NICU: 151 miles) Project Date: 5/1/2006 High-risk obstetrical care can be scary, for both patient and doctor, no matter where it takes place. It can become even scarier, though, in a rural environment such as Grant County, OR, which is more than 2 hours by car from the nearest NICU. Occasionally during rural high-risk pregnancies, the decision must be made whether and when to refer high-risk patients to a more urban setting. This decision is an important one: not only might it affect the health of the mother and her offspring, but it might also impact the cost of malpractice insurance, thereby potentially affecting the entire community. For this project, I initially planned to use a literature search to identify indications for referral of rural high-risk obstetrical patients to an urban setting. I thought that I would discover several sets of guidelines about when referral to urban centers, or at least to obstetricians, is indicated. I planned to use these guidelines to develop a set of criteria to help doctors and patients in Grant County make their decisions. However, an extensive literature search did not reveal any such existing criteria. Next, I interviewed both doctors and pregnant women in Grant County. I have come to the conclusion that the decision of whether to transfer care to the city is a highly variable one and depends entirely on the comfort level and belief system of the patient and doctor who are making the decision. Each choice to stay or to go is a unique decision. With this new understanding, I now realize that my initial goal, of developing a set of uniform criteria that would apply to everyone, was not achievable. Rural medicine doctors and patients are not so easy to fit into a flowchart. Increasing Access to Lactation Services in a Low-Income Population: Developing an Outpatient Program Project Date: 3/20/2006 There are considerable barriers to breastfeeding for low-income, predominantly Latina women in Salem, OR. While lactation services are available to women during their postpartum hospital stay, most outpatient options are inaccessible for these patients. Following a model similar to that of a local pediatric clinic, West Salem Clinic, a federally qualified health center, would like to determine the feasibility of providing outpatient lactation services. Grant money would be needed to offset costs of this program. Additionally, West Salem Clinic should increase the volume of newborns seen to improve the viability of the program. Increasing Awareness and Screening of Postpartum Depression in Klamath Falls Project Date: 10/17/2005 Postpartum depression occurs in approximately 10-22% of women nationally. Risk factors for developing postpartum depression include being a single parent or in an unstable relationship, living at a lower socioeconomic level and having a lack of social and emotional support. Given childbirth is considered such a joyous time in a woman's life, having symptoms of depression can cause women to feel guilty or ashamed. As a result, postpartum depression is under-reported and often physicians do not readily inquire about it. It is an important illness to recognize because not only can it be debilitating for a woman, but it can interfere with essential maternal-infant bonding and can have long-term consequences for the child such as behavioral, cognitive and social developmental problems. Many women in Klamath Falls become mothers at a young age and lack financial resources, stable relationships and emotional and social support. Based on these displayed risk factors, one can infer that postpartum depression is a problem for some women in Klamath Falls. It is therefore important for women to be informed and adequately screened for postpartum depression. As a community project, postpartum and pregnant patients were surveyed to assess the need and interest for more information and screening for postpartum depression. Similarly, several doctors were consulted and expressed interest in providing women written information on postpartum depression and better access to a definitive screening tool. Based on this feedback, an educational pamphlet was created for women with information on understanding the disease, recognizing the symptoms, and knowing the treatments and was made available in the clinic. Similarly, a screening tool specific to postpartum depression was made accessible to the doctors in the clinic to facilitate more consistent screening. Meth Use During Pregnancy Project Date: 7/4/2005 Methamphetamine use during pregnancy is quickly becoming a major problem in rural Oregon. This study attempted to identify the health effects of meth use during pregnancy on the mother and the baby and the resources available in Klamath Falls for meth cessation. The design was a meeting with Molley Boham RN, instructor of prenatal classes at Cascades East Family Practice, and Merlaine Zwartverwer RN Maternity Care Coordinator for Cascades Comprehensive Care to determine the extent of meth use during pregnancy with their patients. A medline search for methamphetamine and pregnancy articles was then done, as well as an extensive Internet search, focusing on meth use in Oregon. I also consulted with Dr. Sohl, perinatologist for Southern Oregon. There are multiple opportunities to reach pregnant women including office visits at Cascades East, office visits with Dr. Sohl, prenatal classes by Molley and home visits by Merlaine. However, there is currently no handouts or material about meth use being used. Therefore, the final product of this project was development of a patient handout for pregnant women coming to Cascades East or in Merlaine's program. Also, a presentation was given to all physicians at Cascades East to educate them about meth. Evaluation of Cervical Cytology Screening in Madras, Oregon: clinical considerations in the context of changing standards of care Project Date: 3/21/2005 The incidence of cervical cancer worldwide has declined sharply since the advent of cervical cancer screening. Current focus on decreasing morbidity and mortality related to cervical cancer rests on improvement of screening methods, development of screening guidelines, and establishment of effective follow-up systems. In the context of continually evolving screening methods and guidelines, clinicians are faced with the task of complying with current standards of care. This is made more difficult by subtle lack of consensus between the leading organizations on when and how to screen. The intent of this project was to evaluate Madras Medical Group’s current screening program and to identify areas for future improvement. By examining Pap data from March 2004- March 2005, creating a spread sheet, and reviewing charts, several trends were identified. Madras Medical Group appears to be over-screening women with history of hysterectomy and women who are older than 70. The intervals between Paps may also be more frequent than necessary, especially in patient who are getting ThinPrep exams. By developing a system to identify women who do not need yearly cervical cytology screening, Madras Medical Group may be able to improve their compliance with current standards of care. Screening and Intervention for Psychosocial Risks: Analysis of Barriers to Appropriate Utilization of Social Services for Obstetric Patients in Astoria, Oregon Project Date: 2/7/2005 Most communities have social services available to, or directed towards the Obstetric population when they are identified as having specific needs. Unfortunately for the community of Astoria, Oregon, the obstetric patients in need may not be aware of the social services available to them. To further complicate the problem, there are no dedicated obstetric social workers in this community to identify high risk Obstetric patients and help them access and navigate the systems that administer these services. The individuals that are called upon to help obstetric patients connect with available resources are the health professionals caring for these patients such as the nurses, midwives and obstetricians, who are already overworked in their existing roles. This community project includes a survey of social services that are available to obstetric patients in the community of Astoria, Oregon: current methods used to identify patients with needs and facilitate connecting patients to these services; and based on this research, recommended changes to improve this process. A comprehensive list of the available social services was compiled to improve patient and provider awareness of available social services. Abuse in Pregnancy Project Date: 1/3/2005 Domestic abuse is a very serious and prevalent issue inthe United States (US). The prevalence of domestic violence is approximately 9.7-29.7%. It is estimated that 3.9- 8.3% women will be abused during pregnancy. In Columbia County, the prevalence of domestic abuse presumably follows national trends. Columbia County Women's Resource Center reports taht 25% of the women who use their crisis hotline and safety shelter are pregnant. Scappoose family clinic has a prenatal packet that is given to all new OB patients but does not include a domestic violence educational brochure. The importance of educating women on the consequences of domestic abuse for themselves and their child is essential to their well-being. Addditionally, providing resources for women who are victims of abuse may save their lives. The development of an educational brochure to give in an existing prenatal package will provide a tool for education and contacts for local resources. The birthing experience in Grant County, Oregon Project Date: 1/3/2005 John Day, like many other rural communities in Oregon, was recently faced with a dilemma: to continue obstetrical care by physicians despite rising malpractice insurance costs or as a community decide to no longer provide these services. While this debate directly influences the physicians and their patients, other allied health care workers in Grant County will also be affected. There are currently two options for obstetrical care in Grant County: the family practice clinic of Drs. Holland and Nichols or the local direct entry midwife, Sherry Lauer-Dress. The physicians provide standard medical care including routine lood work, ultrasounds and deliver at Blue Mountain Hospital. Sherry provides the same care by law, including access to order laboratories and ultrasounds at BMH, homeopathic medicine, and only does home deliveries. The question 1 addressed was threefold: 1. What percentage of women in Grant County are receiving first trimester prenatal care? 2. What form are they choosing- the traditional medical MD model or the alternative nurse-midwife model? 3. What does the lay midwife model entail? The methods include obtaining the breakdown of all birth certificates issued in 2004 from Grant County Health Department, conduction a chart-review of all the Blue Mountain Hospital deliveries, and interviewing Sherry Lauer-Dress and several postpartum patients. The results showed that Grant County issued fifty-seven birth certificates in 2004. Forty-eight of those were delivered at Blue Mountain Hospital (BMH), five were delivered by Sherry and four were delivered in hospitals in other counties. Ninety-five percent of BMH delivered patients had documented 1st or 2nd trimester prenatal care. The midwife patients had an average of 100% 1st trimester care. A summary of the interviews with Sherry and the postpartum patietns are presented in the results section. Exploring Teenage Pregnancy Prevention in John Day, OR: Development of teen education material for birth control method selection Project Date: 7/5/2004 The purpose of this project is to investigate the teenage pregnancy rate and services available to adolescent women in John Day, Oregon. For the past few years, family physicians in John Day have noticed a trend in younger teens becoming pregnant in their small town. They have also reported that adolescent women in their rural community are often more likely to choose to keep their pregnancy and raise their children when compared to their urban counterparts. Teen pregnancies and adolescent childbearing is a important issue for rural towns due to the strain it causes on their limited financial and medical resources as well as the social and health consequences to these parents and their children. Since most programs to prevent pregnancy or adolescent motherhood have targeted young women who reside in metropolitan areas, it is important to evaluate whether similar resources should be directed at rural communities. This project intends to achieve two goals: first, examine the trend in the number of teenage pregnancies in rural counties in Eastern Oregon in comparison to urban counties along the I-5 corridor as well as assess whether or not current programs for teen pregnancy prevention are adequately thwarting the number of adolescent girls becoming pregnant in John Day, OR. Second, as part of the effort of teen pregnancy prevention, a patient education handout was created in order to better assist teens in selecting a birth control method. Facing the loss of obstetrical care in Grant County: Is the community prepared? Project Date: 5/10/2004 Multiple studies have shown that many rural Oregon clinicians performing obstetrical deliveries have already stopped or plan to stop providing this service in the near future. Despite malpractice subsidization efforts such as the Rural Medical Liability Financial Reinsurance, these rates continue to soar, forcing many physicians out of obstetrical practice. The number of physicians who routinely perform obstetrical care in Grant County has dwindled in recent years, such that only one family physician performing OB remains in this isolated county of 8,000 people and 5,000 square miles. If no viable alterative is identified, he, too, will likely stop providing OB care in one month and women will be left to drive long distances for prenatal care and their delivery. In the advent of this potential crisis, this project was designed to assess the community’s preparedness for this transition, as well as childbearing women’s intentions for obtaining prenatal care. These goals were obtained through two methods: 1) a 12-question survey of 33 pregnant and postpartum women that sought information on demographics, risk factors, barriers to receiving care elsewhere, and anticipated plans at the onset of labor, and 2) interviews with community health partners to identify problems, concerns, and potential solutions that might prevent or minimize the impact of the crisis. Survey results revealed a population of many Medicaid patients and first-time mothers. Although most women reported a willingness to travel for prenatal care, 82% stated they would go to the local hospital in Grant County at the onset of early labor signs, suggesting the need for continued emergency OB services. Results of the interviews with health leaders are summarized in a problem/solution format. The results were shared with the same community health partners to assist in their preparedness planning. Emergency Contraception: Knowledge Among and Attitudes at Philomath Family Medicine Project Date: 3/29/2004 Unplanned pregnancy is a major medical, social and public health issue. In the United States, unintended pregnancies account for approximately one half of the 6 million annual pregnancies. These unintended pregnancies result in an estimated 1.4 million abortions and 1.2 million unplanned births each year. Despite better and more effective contraceptive tools, these unintended pregnancy rates persist. Research has demonstrated that emergency contraceptive pills (ECPs) are safe and effective in preventing intended pregnancies. However, for emergency contraception (EC) to be effective women need to know that it exists, how to use it, and be willing to use it. This project was conducted to assess both the awareness of and attitudes toward emergency contraception among female patients and health care providers at Philomath Family Medicine. Data was gathered through the use of two separate surveys: one for patients and a second for providers. Among the 36 women who completed surveys, the majority, 97%, had heard of emergency contraceptive pills, but 17-56% lacked at least one key piece of knowledge about emergency contraceptive pills that may preclude effective use. Additionally, among the 6 health care provider surveyed, all described themselves as at least somewhat familiar with emergency contraceptive pills and all had prescribed them in the past, 5 out of 6 had prescribed them in the past year. Barriers to Obstetric Care in Reedsport, Oregon Project Date: 1/5/2004 With the loss of C-section coverage in 2002, the physicians at Dunes Family Health Care could not continue to provide deliveries at Lower Umpqua Hospital (LUH) in Reedsport due to the terms of the hospital's liability insurance. The object of this project was to examine the barriers to providing obstetric care in Reedsport, because many rural communities are dealing with this issue, and determine what might make rural obstetrics more stable. Planned Cesarean Section Pre-Admission Protocol Project Date: 9/29/2003 Planned cesarean sections place extra demands on the personnel of a small rural hospital such as Harney District Hospital (HDH) in Burns, Oregon. This project looked to identify items that must be addressed before the patient is taken to the operating room. Those steps that were time critical the morning of the procedure were established, and delineated from other items that could be completed the day before the procedure. A checklist and timeline was created to assist nurses in more efficiently preparing patients for their cesarean sections. A patient instruction sheet to be sent home the day before admission was also created to have patients arrive at the hospital better prepared and ready for surgery. Breastfeeding in John Day and Grant County: Development of a Patient Handout to Encourage Breastfeeding Project Date: 9/29/2003 The advantages of breastfeeding are well documented in scientific literature, and it is apparent that it is in the best interests of public health to encourage breastfeeding. The purpose of this project was to identify the resources available to residents of John Day and Grant County with regard to breastfeeding support, and to encourage breastfeeding through the use of a handout in the clinic. National and local statistics on breastfeeding were noted, as well as possible reasons that women quit breastfeeding. Benefits of breastfeeding were researched and summarized, and online and local resources were included in the flyer as well in an attempt to improve breastfeeding participation. The small numbers of women giving birth in Grant County made it unrealistic to determine the impact of the handout during the rotation, but the handout was well received by clinic physicians and staff. Age Trend of First-Time Mothers and the Implications for a Central Oregon Community Clinic Project Date: 8/18/2003 Young motherhood carries with it not only risk factors for the mother and the child, but it also serves as a proxy for a number of social, economic, and behavioral risk factors contained within the community. This has implications for the mothers and their children, as well as places demands on the healthcare system and community resources. While the national trend is that women are becoming mothers at an older age1, an investigation into the trend for a Central Oregon community clinic had never been done. By examining prenatal visit records, I found that though the number of young mothers has not increased over the past decade, it has not significantly decreased. The number of very young and late teen mothers has declined, however the number of 17-18 year olds who become pregnant has increased over the past decade. Furthermore, because the entire youth population is increasing out of proportion to older age cohorts, the average age of motherhood is decreasing. In addition, I verified the presumption that women who first become pregnant at a young age do tend to have more children than women who become pregnant when older. These findings suggest that the factors that are influencing women to delay motherhood on the national level are not acting on a local level. This study does not investigate the intent of pregnancy and young motherhood among this community, nor the many potential socioeconomic and behavioral factors that have been associated with young motherhood. Hopefully, this project will serve as an entrance into an issue that deserves further attention. Impact of Surgery on Lower Umpqua Hospital, Part II: Provision of Obstetrical Services, a Community Needs Assessment Project Date: 11/4/2002 Following an era of business success, growth of faculty, and outstanding service, Lower Umpqua Hospital is now searching to hire a general surgeon. A prior study examined the economic impact of surgery at the Lower Umpqua Hospital (Melvin, 2001). In this project, we assess the community impact of services provided by surgery. In particular, the Lower Umpqua Hospital has recently announced it will not provide routine obstetrical care (Vail, 2002). The Dunes Family Health Care also announced it will not provide third trimester prenatal care (Law, 2002). Community demographic and socio-economic climate, and health care services currently provided are described. A needs assessment describes the current market share, community vital statistics, and economic implications. Finally, the impact of cessation of services is addressed in terms of community reaction, a call for community response, and case-scenarios. Adoption and Rural Family Practice Project Date: 9/23/2002 Adoption is an important option to be considered by mothers who are facing unplanned pregnancy. Often women who are unprepared on several fronts for parenthood and who have neither access to nor acceptance of abortion as an option are not introduced to this third and vital possibility for their child. Current societal views and lack of physician education may limit how often it is discussed, especially within the scope of a rural family medicine practice. This project examined the current climate regarding adoption in Lebanon/Sweet Home and attempted to gather information on physician/counselor education and readiness to offer adoption as an option to their patients/clients. One-on-one interviews, journal research, and a survey distributed among family medicine and OB-gyn physicians, adult and family service counselors, and school guidance counselors were employed to gather information. It was evident that there is much work to be done in providing instruction and information about adoption to those on the front lines of dealing with unplanned pregnancy Who Will Catch the Babies? The Impending Medical Liability Crisis in Grant County, Oregon Project Date: 3/25/2002 With the rising cost of medical liability insurance premiums, it is becoming unaffordable to practice obstetrics in Grant County, Oregon. One of Grant County's five physicians has already decided to quit practicing obstetrics and if premiums increase much more, it is likely that the remaining four will follow the same path. The result will be additional problems with access to care in rural communities. Expecting mothers in Grant County will have to drive over two hours for obstetrics care. In this paper I will look at how other states in the country are dealing with this problem and what the OMA and AMA are recommending for further action. With this informaiton, I will assess what the physicians and residents of Grant County can do to initiate change to avoid a medical liability crisis in Oregon. The Rural Epidural: Looking at Protocol-Driven, Nurse-Managed Epidural Anesthesia in the Rural Setting. Project Date: 11/5/2001 Rural location and financial constraints make it difficult to provide 24-hour in-house anesthesia coverage for elective obstetric epidurals at Lebanon Community Hospital (LCH). To ease this burden, LCH shares call with Albany Anesthesia Group (AAG). AAG agreed to take call under the condition that for elective epidural anesthesia, the anesthesiologist/anesthetist will place the catheter but the labor and delivery nurses will manage and adjust the epidural via physician-designed protocol. Labor and delivery nurses at LCH are uncomfortable with this agreement as the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) states that this falls outside of the scope of practice of a labor and delivery nurse. Practicing outside of ones' scope leaves the nurse vulnerable to individual litigation, loss of licensure and threat of termination. The Oregon State Board of nursing has yet to formally rule on this issue. In the meantime, labor and delivery nurses at LCH have been trained to manage epidural anesthesia via protocol and have been doing so for the past six months. To date, no objective measures have been documented to monitor safety and efficacy of this practice. This study looks at current documentation standards and recommends specific measurable events to collect for further study. Back to subject search page or search by preceptor site