Improving surveillance for the hidden half of fetal-infant mortality: a pilot study of the expansion of the Pregnancy Risk Assessment Monitoring System to include stillbirth

Racial and ethnic inequities in stillbirth in the US: Looking upstream to close the gap: Seminars in Perinatology

Though stillbirth rates in the United States improved over the previous decades, inequities in stillbirth by race and ethnicity have persisted nearly unchanged since data collection began. Black and Indigenous pregnant people face a two-fold greater risk of experiencing the devastating consequences of stillbirth compared to their White counterparts. Because race is a social rather than biological construct, inequities in stillbirth rates are a downstream consequence of structural, institutional, and interpersonal racism which shape a landscape of differential access to opportunities for health. These downstream consequences can include differences in the prevalence of chronic health conditions as well as structural differences in the quality of health care or healthy neighborhood conditions, each of which likely plays a role in racial and ethnic inequities in stillbirth. Research and intervention approaches that utilize an equity lens may identify ways to close gaps in stillbirth incidence or in responding to the health and socioemotional consequences of stillbirth. A community-engaged approach that incorporates experiential wisdom will be necessary to create a full picture of the causes and consequences of inequity in stillbirth outcomes. Investigators working in tandem with community partners, utilizing a combination of qualitative, quantitative, and implementation science approaches, may more fully elucidate the underpinnings of racial and ethnic inequities in stillbirth outcomes.

Fusing stillbirth parent advocacy and epidemiology to address the US stillbirth crisis

This narrative describes how a stillbirth advocate and an epidemiologist have worked together to advocate for federal legislation to address stillbirth in the United States. It alternates between each of their perspectives to illustrate how they have leveraged their complementary skills and experiences with the hope that fewer families will experience the tragedy of stillbirth.

Participation in survey research among mothers with a recent live birth: A comparison of mothers with living versus deceased infants - Findings from the Pregnancy Risk Assessment Monitoring System, 2016-2019

BACKGROUND

Despite high infant mortality rates in the United States relative to other developed countries, little is known about survey participation among mothers of deceased infants.

OBJECTIVE

To assess differences in survey response, contact and cooperation rates for mothers of deceased versus. living infants at the time of survey mailing (approximately 2-6 months postpartum), overall and by select maternal and infant characteristics.

METHODS

We analysed 2016-2019 data for 50 sites from the Pregnancy Risk Assessment Monitoring System (PRAMS), a site-specific, population-based surveillance system of mothers with a recent live birth. We assessed differences in survey participation between mothers of deceased and living infants. Using American Association for Public Opinion Research (AAPOR) standard definitions and terminology, we calculated proportions of mothers who participated and were successfully contacted among sampled mothers (weighted response and contact rates, respectively), and who participated among contacted mothers (weighted cooperation rate). We then constructed multivariable survey-weighted logistic regression models to examine the adjusted association between infant vital status and weighted response, contact and cooperation rates, within strata of maternal and infant characteristics.

RESULTS

Among sampled mothers, 0.3% (weighted percentage, n = 2795) of infants had records indicating they were deceased at the time of survey mailing and 99.7% (weighted percentage, n = 344,379) did not. Mothers of deceased infants had lower unadjusted weighted response (48.3% vs. 56.2%), contact (67.9% vs. 74.3%) and cooperation rates (71.1% vs. 75.6%). However, after adjusting for covariates, differences in survey participation by infant vital status were reduced.

CONCLUSIONS

After covariate adjustment, differences in PRAMS participation rates were attenuated. However, participation rates among mothers of deceased infants remain two to four percentage points lower compared with mothers of living infants. Strategies to increase PRAMS participation could inform knowledge about experiences and behaviours before, during and shortly after pregnancy to help reduce infant mortality.

Design and Methodology of the Study of Associated Risks of Stillbirth (SOARS) in Utah

OBJECTIVES

The Utah Study of Associated Risks of Stillbirth (SOARS) collects data about stillbirths that are not included in medical records or on fetal death certificates. We describe the design, methods, and survey response rate from the first year of SOARS.

METHODS

The Utah Department of Health identified all Utah women who experienced a stillbirth from June 1, 2018, through May 31, 2019, via fetal death certificates and invited them to participate in SOARS. The research team based the study protocol on the Pregnancy Risk Assessment Monitoring System surveillance of women with live births and modified it to be sensitive to women's recent experience of a stillbirth. We used fetal death certificates to examine survey response rates overall and by maternal characteristics, gestational age of the fetus, and month in which the loss occurred.

RESULTS

Of 288 women invited to participate in the study, 167 (58.0%) completed the survey; 149 (89.2%) responded by mail and 18 (10.8%) by telephone. A higher proportion of women who were non-Hispanic White (vs other races/ethnicities), were married (vs unmarried), and had ≥high school education (vs <high school education) responded to the survey. Differences between responders and nonresponders by maternal age, gestational age of the fetus, or month of delivery were not significant. Among responders, item nonresponse rates were low (range, 0.6%-5.4%). The question about income (4.8%) and the questions about tests offered and performed during the hospital stay had the highest item nonresponse rates.

CONCLUSIONS

The response rate suggests that a mail- and telephone-based survey can be successful in collecting self-reported information about risk factors for stillbirths not currently included in medical records or fetal death certificates.

The Pregnancy Risk Assessment Monitoring System (PRAMS): Overview of Design and Methodology

Data System. The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing state-based surveillance system of maternal behaviors, attitudes, and experiences before, during, and shortly after pregnancy. PRAMS is conducted by the Centers for Disease Control and Prevention's Division of Reproductive Health in collaboration with state health departments. Data Collection/Processing. Birth certificate records are used in each participating jurisdiction to select a sample representative of all women who delivered a live-born infant. PRAMS is a mixed-mode mail and telephone survey. Annual state sample sizes range from approximately 1000 to 3000 women. States stratify their sample by characteristics of public health interest such as maternal age, race/ethnicity, geographic area of residence, and infant birth weight. Data Analysis/Dissemination. States meeting established response rate thresholds are included in multistate analytic data sets available to researchers through a proposal submission process. In addition, estimates from selected indicators are available online. Public Health Implications. PRAMS provides state-based data for key maternal and child health indicators that can be tracked over time. Stratification by maternal characteristics allows for examinations of disparities over a wide range of health indicators.

Fetal death certificate data quality: a tale of two U.S. counties

PURPOSE

Describe the relative frequency and joint effect of missing and misreported fetal death certificate (FDC) data and identify variations by key characteristics.

METHODS

Stillbirths were prospectively identified during 2006-2008 for a multisite population-based case-control study. For this study, eligible mothers of stillbirths were not incarcerated residents of DeKalb County, Georgia, or Salt Lake County, Utah, aged ≥13 years, with an identifiable FDC. We identified the frequency of missing and misreported (any departure from the study value) FDC data by county, race/ethnicity, gestational age, and whether the stillbirth was antepartum or intrapartum.

RESULTS

Data quality varied by item and was highest in Salt Lake County. Reporting was generally not associated with maternal or delivery characteristics. Reasons for poor data quality varied by item in DeKalb County: some items were frequently missing and misreported; however, others were of poor quality due to either missing or misreported data.

CONCLUSIONS

FDC data suffer from missing and inaccurate data, with variations by item and county. Salt Lake County data illustrate that high quality reporting is attainable. The overall quality of reporting must be improved to support consequential epidemiologic analyses for stillbirth, and improvement efforts should be tailored to the needs of each jurisdiction.