Pregnancy Outcomes in American Women

Sean Flaherty, Department of Economics, Franklin & Marshall College
Alison Kibler, Department of American Studies and Program in Women and Gender Studies, Franklin & Marshall College
Kirk Miller, Department of Biology, Franklin & Marshall College
Berwood Yost, Floyd Institute Center for Opinion Research, Franklin & Marshall College

Pregnancy Outcomes CoverThe US is currently ranked 28th in the rate of infant mortality, the second lowest ranking in the developed world. This upper-division seminar for juniors and seniors examines the pressing civic problem of poor pregnancy outcomes in American women by using locally collected data and multi-disciplinary approach. The course is team taught by a biologist, an economist, a statistician, and a cultural historian of gender, with guest lecturers provide expert coverage of topics related to infant mortality and its prevention, such as medical practices, behavior, and environmental factors. The science topics addressed include the stages of human pregnancy, genetic testing, and the impact of pharmaceuticals, toxins, and nutrition on fetal development. Through readings, presentations and discussions students explore unanswered questions at the intersection of science and public policy, including “what is good prenatal care and does access to it improve pregnancy outcomes? What are the impact of alcohol, smoking, and teratogens on fetal health? When does the fetus become a person with rights equal to the mother’s? How do economic status and cultural practices affect pregnancy outcomes?

An overarching goal of the course is to give students experience with the evaluation and use of evidence drawn from multiple sources, so that the construction and defense of arguments based on statistical data is emphasized. Every week pairs of students lead their peers in a data analysis of results drawn from three local surveys, one of African American and Hispanic women in Lancaster city, one of Amish women in Lancaster County, and a 2002 survey of all women of childbearing age in Central Pennsylvania that was the basis of the Central Pennsylvania Women’s Health Study. Students may complete the course by doing an in-depth research paper or a service-learning project. The course was first taught in 2006 and was originally funded as part of a Pennsylvania Department of Health grant to the Penn State College of Medicine to create the Pennsylvania Center of Excellence for Research on Pregnancy Outcomes.

Course Learning Goals for Instructors and Students

Instructor Goals:

The instructors will teach students:

  • To perform statistical analyses using data from different sources
  • The basic biology involved in pregnancy and infant mortality
  • The competing and/or non-medical explanations (social, economic, cultural) for poor pregnancy outcomes
  • The ethical and legal debates and issues surrounding policy aimed at improving pregnancy outcomes

Student Goals:

Students will be able to:

  • Use evidence, including survey data, from multiple sources and of multiple types
  • Evaluate the quality of data and of the conclusions others have made from that data
  • Examine a complicated and urgent public health problem and to discuss and debate with one another proposed solutions to the problem
  • Make effective presentations and respond confidently to questions about their analysis
  • Write short, cogent position papers on narrowly defined topics
  • Develop a longer research project and paper

Linking Science and Social Issues

How Pregnancy Outcomes in American Women Links Biology and Statistics to Social Issues

Our course examines pregnancy outcomes in women. One measure of a nation’s health is the outcomes of the pregnancies of its mothers. In infant mortality, for example, the rank of the United States in the world fell from 11th in 1960 to 28th in 2002.

[Go to gapminder.org and open Gapminder World. Plot infant mortality as a function of income per person. Run the plot from, say, 1940 to the present and see that, although infant mortality in the United States declined during the last half of the twentieth century, that in other developed countries declined more quickly.]

We examine pregnancy outcomes from as many perspectives as we can think of:biological, sociological, economic, policy, personal. The table below and the sentences below it show some of the ways we try to link science and issues in science with social and policy issues that can be addressed, in part, from the perspective of science.

Science Social/Policy Issue
Biology of Pregnancy Miscarriage
Spontaneous Abortion
Embryonic
Development/Pharmaceuticals
Pregnancy Outcomes Infant Mortality
Social Factors Influencing
Fetal Origins of Adult Disease
Issues Surrounding Pregnancy and its Outcomes: Culture, Race, Class, Environmental Concerns, Nutrition
Health Related Surveys How to Interpret Survey Responses
Pregnancy Outcomes in American Minorities Racism
The Weathering Hypothesis
Personal vs. Public Responsibility
Alcohol and Tobacco Use Turning Scientific Evidence into Public Policy
Personal vs. Public Responsibility
Amish Pregnancy Outcomes Model and Iconic Ethnic Groups
Genetic Testing
Genetic Disorders in Amish Communities
Genetic Testing Uses of Genetic Testing
Air and Water Pollution How to Protect Women from Pollution
Teratogens How to Collect Information on the Safety of Drugs for Use by Pregnant Women
Birth Defects Children with Birth Defects
Vulnerable Periods in Embryonic Development Use of Pharmaceuticals During Pregnancy
Midwifery Women’s choices for birth place
Control of birth
Pregnancy Outcomes in Hispanic Women The Hispanic Paradox
Medical Care Delivery to Poor Women How Should Medical Care be Delivered (and Paid For?)
Abortion Abortion
A Woman’s Right and Power to Control Her Body

Some of the many scientific or medical questions that are directly linked to social, economic, or cultural conditions include:

  • Does access to prenatal care improve pregnancy outcomes? What constitutes good prenatal care?
  • Are women of color “bad mothers,” or are they unfairly cast as such in American media and do they suffer from heightened state intervention (such as arrest and incarceration) for misbehavior like drug use while pregnant because of racism?
  • What are the policy implications of alcohol, abortion, and teratogens: balancing a pregnant woman’s body autonomy/personal freedom with the life of the fetus.
  • When does the fetus become a person with rights equal to the mothers?

In the future we may change the issue addressed in the course title. Other important civic questions under consideration that illuminate the connection between science and public policy are urban education, water, or crime.

The Course

A major priority in the design of this course is the engagement of students as scientists and citizens. This is accomplished through the variety of techniques described below.

Course Syllabus

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Course Introduction

This seminar will explore women’s health and pregnancy outcomes from the perspectives of science, social analysis, and policy. We will read and discuss materials on pregnancy outcomes, and we will examine results of surveys of all women of child-bearing age in central Pennsylvania, of Amish women in Lancaster County, and of African-American and Hispanic women in Lancaster City. Students will be responsible for preparing for, participating in, and leading discussions and will also explore a topic in depth in a research project. This course is supported by funds from the Pennsylvania Department of Health.

Poor pregnancy outcomes are linked to personal behavior, environmental effects, sociological influences, and genetics, among many other factors, and these factors interact with each other. Our intention is to understand different factors affecting pregnancy outcomes, to compare pregnancy outcomes among different groups of women, to comprehend in depth and from multiple perspectives a pressing health crisis and the interactions of factors that affect it, and to assess scientific data.

Course Design

Public Health Research is presented in a series of modules, each one week (two class meetings) long. On the first day of a week, students hear a presentation by a course instructor or guest speaker on a subject relevant to women’s pregnancy outcomes. This is always accompanied by readings, usually from the primary literature, relevant to the topic of the day. On the second day, there is a discussion of the topic, initiated by consideration of questions posed by faculty and about which students have written a short essay. In addition, on the second day, teams of students lead the class in an examination of an analysis of data they have performed.

Pedagogies and Methodologies

The course is discussion-based, and students must prepare for discussions by doing the assigned reading and writing a short essay on a question for discussion that day. The first two times the course was offered, students, working in teams, led the day’s discussion. This worked well and we will return to this in the future. Students must participate in discussions. Students also write a longer research paper, with intermediate due dates. A service-learning project may substitute for the research paper.

Course Assignments and Expectations

Your assignments for class are: to be prepared for and participate in discussions, to write 11 short essays that will help you prepare for discussions, to lead an analysis of data and the discussion of it with a partner, and to write a research paper that explores in depth a topic in
pregnancy outcomes.

A typical class week will have a presentation on Tuesday and a discussion on Thursday. Presenters will provide us with readings that will help us prepare for their presentation and for the Thursday discussion. In addition, they will provide us with a short list of questions to help guide our discussion and data analysis, and as topics for your short essays.

Expectations for Discussions

Students should come to class willing and able to help conduct a fruitful discussion by having done the appropriate reading and by having individually explored an idea or two that they think may – or ought to – come up in the discussion. Of course, we will only know if you have prepared for the discussion if you actually contribute to it. Your class participation grade, worth 20% of your overall course grade, will be based in large part on the quality of your participation in discussions.

To evaluate your class participation, we will use guidelines from the website of the Princeton University Dept. of History Guidelines. We will provide you with feedback on your participation.

Grades

Your final grade will be based on the following percentage distribution:

Participation – 20%
Short Essays – 20%
Data Analysis – 20%
Research Paper – 40%

Writing and Analysis

To help prepare for discussions, students will write short essays, each answering a question for that day’s discussion. There will be 11 of these, each corresponding to one of the discussions, each due at the beginning of class on the day of discussion, and each will answer one of the questions posed to help guide and focus our discussion. An essay should be one page, typed, double spaced, and approx. 300 words. We will grade them on a check-plus, check, check-minus, 0 scale. In these essays you do not need an introduction or conclusion; you should get straight to the point. An excellent essay will show an understanding of the assigned readings; make interesting connections, comparisons, or contrasts between readings; and provide original insights into the materials. Essays will not require any additional research. No late papers will be accepted. Your essays are worth 20% of your overall course grade. We will provide you with feedback on your essay promptly.

Analysis

Students will work in groups of 2 or 3 to lead the class in an analysis of data using the results from the surveys of groups of Central Pennsylvania women. Questions relevant to that week’s topics will be provided to help guide these analyses. Analyses will be done using the statistics program SPSS, which is available on the College Software Server. Surveys and survey results are on the course edisk.

The purpose of these analyses is to use data to make evidence-based decisions on questions related to pregnancy outcomes, decisions that may affect policy, treatment, or behavior towards women and their babies. Even more than that, the purpose is to show how to use data to help make
decisions. Analysis leaders will be responsible for initiating and advancing our collective understanding of the material. We (especially Professor Yost, the class expert on surveys and survey analysis) will provide guidance on the logic of analysis and on using SPSS, but we leave the project relatively open-ended to make room for your creativity. Groups will be asked to show the class how they arrived at the conclusions they drew. Methods of analysis, and critical thinking using data, are the key elements of this. It is our expectation that the sophistication of these analyses will increase as the semester progresses. Our class meets in a room where we can display computer output so how analyses were done should be easy to show.

Analysis teams may wish to prepare introductory remarks that explore the connection between the readings and the previous presentation and how data might be used to ask and answer questions about them; they may wish to prepare handouts of salient points or questions for further
discussion or tables and charts that are useful in informing our discussion of the issues. The form of the student-led analyses is up to the student leaders of them. These should take-up no more than 30 minutes of class time.

Profs. Yost and Miller will host a series of workshops on using SPSS in Lsp-143 (the Life Sciences and Philosophy Building Advanced Statistics Laboratory: just opposite the front door) every other Wednesday afternoon at 2:30 p.m. The first workshop will be on Wednesday January 30; others will be every other week thereafter (Feb. 13, Feb. 27, Mar. 12, Mar. 26, Apr. 9). We will have no particular agenda at these meetings; we will help you get started with your analysis and answer questions. We are also available to help you at other times by appointment.

Analysis leaders are not responsible for writing a short essay for the day they lead an analysis. Analysis leaders are responsible for keeping the class on schedule so all the day’s work is accomplished.

Your performance as an analysis leader will count for 20% of your course grade. We will provide you with feedback on your performance as soon as possible after you have been an analysis leader. If you have prepared materials for your presentation, SPSS files, PowerPoint slides, or handouts, we ask that you turn them in to us after your presentation.

You are each assigned to one leadership team (see above). If you would prefer to be on an analysis leadership team to which you have not been assigned, you may negotiate a mutually agreeable swap. If you do so, please inform us as soon as you have made the arrangement.

Research Project

Each student will produce a 4-5,000 word research paper that explores in depth a topic in pregnancy outcomes, broadly defined. The final paper will be due May 6. Each of you will work with one of us; we will help you decide which one of us is most appropriate based on the topic you choose (see below). If you wish, and one of our guests agrees, you may seek help from him or her. There are also alternatives to this project (see below).

Alternatively, you may fulfill this part of the requirements of the course with service-learning or with an applied project or paper. The service-learning alternative may be through SouthEast Lancaster Health Services or another of the College partners. The College Ware Institute will be able to help you with this; see their Guide to Service Learning. This alternative will require written work or presentation to connect your service to the context of the course. The other alternative is to write a more applied or advocacy paper; this might involve data analysis and conclusion, possibly growing from your in-class analysis project, or using data to advocate a policy position or change.

Evaluating Learning

Student Evaluation

Students are evaluated on how well they:

  • participate in discussions
  • work with a partner to analyze survey data sets to answer specific questions
  • work with a partner to lead a discussion on a particular topic (iterations 1 and 2, not 3)
  • write a research paper on a topic related to pregnancy outcomes

Course Evaluation

An advantage of team-teaching is the continuous, soul-searching, evaluation of a course’s success. (This may be the disadvantage, too.) The course is evaluated by students using the Franklin & Marshall “Student Perception of Teaching” instrument.. One measure of the course’s success is that it has been oversubscribed every year it has been taught.

Background and Context

Pregnancy Outcomes in American Women, a course at Franklin & Marshall College in Pennsylvania.
Sean Flaherty, Department of Economics.
Email:Sean.Flaherty@fandm.edu;
Alison Kibler
, Department of American Studies and Program in Women and Gender Studies.
Email: Alison.Kibler@fandm.edu;
Kirk Miller, Department of Biology.
Email: Kirk.Miller@fandm.edu;
Berwood Yost, Floyd Institute for Public Policy Analysis.
Email: Berwood.Yost@fandm.edu.

Course History

The Central Pennsylvania Center of Excellence (COE) for Research on Pregnancy Outcomes is a project of Penn State University and the partnering institutions of Franklin and Marshall College and Lock Haven University of Pennsylvania. Participating faculty, including Sean Flaherty, Kirk Miller, and Berwood Yost, at Franklin & Marshall College designed “Public Health Research: Pregnancy Outcomes in American Women, ” based on this research project. Alison Kibler joined Kirk Miller and Berwood Yost in the second year of the course. For the third iteration, all four of faculty participated. Sean is in the Department of Economics, Kirk, Department of Biology, Berwood, Director of the Floyd Institute Center for Opinion Research, and Alison, Department of American Studies and Program in Women and Gender Studies, Franklin & Marshall College.

Each time the course was offered it was over-subscribed, over its limit of 24 students. Several science majors, many social science majors, many majors in Special Studies: Public Health, and a smattering of humanities majors enrolled. Women were a large majority.

Place in the Curriculum

Our course has no formal role in F&M’s undergraduate curriculum. However, we see it as a capstone course that brings together students from various disciplines in the sciences and social sciences and students interested in policy and service to explore a topic of importance in depth. The course draws on Franklin & Marshall nationally recognized programs in pre-healing arts, public policy (and health policy in particular) and American studies. It also exemplifies F&M’s longstanding commitment to community-based learning and to connecting student learning to civic problems and questions of special concern to Lancaster city and the surrounding communities.

Funding Sources

Funding by the Pennsylvania Department of Health to the Penn State College of Medicine permitted the creation of the Pennsylvania Center of Excellence for Research on Pregnancy Outcomes. The creators of the course argued successfully that the education of future leaders in health care was important for the improvement of pregnancy outcomes and the course was included as a project of the Center.

This funding also allowed the Floyd Center for Opinion Research to perform two surveys that provide an important component of the course’s design: a survey of a sample of 355 African-American and Hispanic women in Lancaster city and a survey of a sample of 288 Amish women in Lancaster County. In addition, we have access to the results of a survey of 2002 women in Central Pennsylvania that was the basis of the Central Pennsylvania Women’s Health Study. The three surveys used the same instrument.

Resulting Projects and Research

Faculty Research

“Health Status, Health Conditions, and Health Behaviors Among Amish Women: Results from the Central Pennsylvania Women’s Health Study (CePAWHS).” Women’s Health Issues , Volume 17 , Issue 3 , Pages 162 – 171 K . Miller , B . Yost , S . Flaherty , M . Hillemeier , G . Chase , C . Weisman , A . Dyer. Link to the full length PDF version

Recognition for Course

Crable, Ad, “Faculty studies, team-teaches course about pregnancy outcomes in American women,” Franklin & Marshall Magazine, Spring 2007, p. 10-11.